Endoscopic Calcaneoplasty for Haglund’s Deformity

Endoscopic Calcaneoplasty for Haglund’s Deformity from HMP on Vimeo.

In this video, Dr. Ehredt Jr, DPM, discusses endoscopic calcaneoplasty as an alternative to open surgery for Haglund’s deformity.

Dr. Duane Ehredt:  This is Duane Ehredt Jr, DPM, associate professor at Kent State University College of Podiatric Medicine in Division of Foot and Ankle Surgery, and foot and ankle surgeon at St. Vincent Charity Medical Center in Cleveland, Ohio.

Question 1: How do you perform an endoscopic calcaneoplasty for Haglund’s deformity?

Dr. Ehredt:  First, defining endoscopic calcaneoplasty is important because not many folks know what this is. Essentially, it's a minimally invasive procedure at decompressing the posterior calcaneus at the insertion of Achilles tendon. Traditionally, for painful Haglund's deformity, and sometimes for insertional tendonitis.

The way we perform this is typically in a prone position, although you can perform it in a supine position. I prefer prone, as it does give more direct access. However, some patients who are either obese, or have positioning problems, or can't be intubated in a traditional endotracheal fashion can benefit from the supine position.

However, it's a little bit more complicated in that fashion. Things that you need is usually a smaller arthroscope. I prefer 2.7-millimeter 30-degree arthroscope and the associated small arthroscopic instrumentation, like 3.5-millimeter dissectors as well as a 4.0-millimeter full-radius bur.

Additionally, I use a Kirschner wire that is placed preoperatively under fluoroscopic guidance to aid in the resection of the painful bump or spur on the posterior calcaneus. That way, I don't need to take a bunch of x-rays during the procedure.

I can directly visualize that Kirschner wire in the operative field under the guidance of the endoscope. The procedure's performed by palpating the insertion of the Achilles tendon and making a medial and lateral portal approximately one centimeter cranial to the insertion of the Achilles tendon on the calcaneus.

There's a little bit of a sweet spot back there where you can fit your camera and instrumentation in as well as be able to get to all the surfaces of bone required. I first start off by using a 3.5-millimeter dissector and freeing all the soft tissue off of the posterior calcaneus as well as the...Traditionally, there's a painful bursa there as well.

I dissect that all away so that I can visualize the bony prominence of the posterior calcaneus. Once that's easily visualized, I'll insert a 4.0-millimeter bur and basically bur the bone down until I get to the level of the Kirschner wire that I placed preoperatively, and I can directly visualize that.

At that point, it's important to stop utilizing the bur, because the bur can cut through the Kirschner wire if you're not careful, and that would require you then to have to open up the procedure, thereby converting it to a standard open procedure in order to remove that Kirschner wire.

I then transition to the use of a small bell-shaped reciprocating rasp. Using fluoroscopic guidance, then use the rasp to smooth down any bony spicules that are remaining from the burring part of the procedure, then flush out the area with copious amounts of saline or lactated Ringer's, whichever you prefer. Then, close the incisions up with a [inaudible 4:03] suture.

It's a very easy procedure to perform. I traditionally pair this with a gastrocnemius recession as well, as most of these folks have an equinus contracture on top of it. That's something else that's very easy to perform, especially if you're doing a prone. Everything is right there, great visualization very easy to obtain.

Quite frankly, it shouldn't take much more than 30 to 35 minutes once you get skilled in understanding what it is that you're visualizing.

Question 2: What are the indications and patient selection criteria for the procedure?

Dr. Ehredt:  The indications for endoscopic calcaneoplasty are anyone who has a painful Haglund's deformity, otherwise known as a pump bump, a painful prominence of bone and posterior calcaneal region, usually right around the insertion of the Achilles tendon.

Those folks have failed traditional conservative therapy, consisting usually of heel lifts, posterior leg stretching exercises, physical therapy, injection therapy, that kind of thing. Traditionally, folks do OK with those, and usually, we give them about six months of time to attempt some form of conservative therapy.

Once they fail, that's when we take them in for surgical intervention. There is a specific patient selection process for this procedure. As we know, Haglund's deformity and insertional tendinopathy of the Achilles has three components to it.

There's an equinus component that the majority of these patients present with, as well as a painful prominence of bone. Traditionally, these folks have a higher-arched foot type, so you may see that in combination with it, which then leads to insertional tendinopathy and calcific tendinosis of the distal Achilles tendon. That's more in the severe cases.

Those patients, the patients with severe disease and more traditional spurring of the Achilles tendon do not do well with this procedure. You can't frankly put a scope inside a tendon. You can put it in a potential space, like the Kager's triangle, which is what we do for the more moderate or mild deformities that we see.

I like to get an MRI in my patients. If there's more than 50 percent of the distal Achilles that is showing signs of tendinosis in disease, then I perform that procedure open and not in endoscopic fashion.

As long as they have less than 50 percent disease, I feel pretty confident that the gastrocnemius recession, number one, will release the abnormal forces on the Achilles tendon, and then number two, the endoscopic calcaneoplasty will adequately decompress that posterior calcaneal space in the Kager triangle space that will allow for adequate offloading of that posterior calcaneal region.

Question 3: How do the outcomes of endoscopic calcaneoplasty differ from traditional open procedures?

Dr. Ehredt:  This is a question that myself and my colleagues at Kent State have formerly researched. It definitely does speed up the process. In our cohort of patients, we found that the average return to work was about 7 1/2 weeks.

This is markedly better than a traditional open approach is. The traditional open approach usually centers around approximately an 8 cm–long incision, either directly posterior at the midline of the Achilles tendon. Sometimes, people make that incision median or laterally as well.

Either way, that area back there has a tendency for wound problems and slow wound-healing issues. Because of that, you have to baby an open procedure upfront and make sure that the wound heals, because there's not a whole lot of space between the environment and the Achilles tendon.

Once that gets exposed, you're dealt with plastic surgery techniques, wound vacs, and all kinds of things to get that closed. With an endoscopic approach, you simply have two poke holes at the posterior calcaneal region. I personally have never had any complication with those incisions themselves.

You do sometimes see sural nerve neuritis that can happen from scarring. That's exceedingly rare. In our cohort of patients, we only saw two of those, and that was a transient thing that resolved on its own. There has been some reports in the worldwide literature of posterior tibial nerve injury during this procedure.

However, I personally find this very hard to believe, hard to visualize how you could get your camera or your scope into the posterior leg that far. This is a very superficial procedure, so if you know your anatomy and understand where you are, I don't think that you would have a problem with that.

Quite frankly, the real only complication that I've seen with this would be lack of efficacy. Any surgery could have a lack of efficacy, or at least, a lack of expected efficacy. Sometimes, patients do have pain that persists.

Although, I found this very, very rare in the endoscopic cohort, as they have more of a mild-to-moderate disease process to begin with. That is a potential complication.

The outcomes in my hands are much better. Patients tend to be much more happy, much more appreciative of the procedure. Patients like to know that there are advanced procedures out there that minimize the incision and can potentially get them back to work sooner.

With foot and ankle surgery, it always comes down, in terms of return to work as to what they do for a living. If someone is a landscaper, or has a very physical manual labor job, it may take them longer to get back to work.

If they work behind a desk, usually they can go back to work the following week. In our cohort of patients, again, I've found that they return to work in about 7 1/2 weeks and do very well.

I've had no return trips for this procedure. I've probably performed somewhere between 40 and 50 of these myself, and I haven't had any, to my knowledge, anyway, that have gone back to the operating room for an open procedure. If that was the case, you don't burn any bridges with the procedure.

I explain this to patients, it's very similar to the cheilectomy of the first MTP joint. With a cheilectomy procedure, if you need to go back in later to do a fusion or something more extensive, you don't burn any bridges with that, and the same here. There's not any damage done.

If there is lack of efficacy, you can simply open it up like you would traditionally, debris the Achilles tendon traditionally and/or transfer the flexor hallucis longus tendon if necessary. It would be very easy to do. Again, I haven't done any of those today, but would not be hesitant to do so if required.

Question 4: Final thoughts?

Dr. Ehredt:  A lot of folks in ankle arthroscopy will traditionally utilize a fluid pump for fluid management. I do personally like that. You can hang your fluid to gravity.

However, I like to be able to clear out that posterior calcaneal space after the surgery is done and flush that out, and it helps to have a power flush to do that. If you're going to use a power pump, you have to make sure that you set the pressure settings low.

I like to set it to about 15 millimeters of mercury. The reason why is because that space back there is not a joint. It's a potential space. I don't want fluid extravasating throughout the posterior leg or potentially creating a compartment syndrome or something like that.

I know that's been documented. It's a theoretical thing. I've never seen a compartment syndrome after any arthroscopy, but it's something to keep an eye for. I keep my pump pressures down at 15 millimeters of mercury.

I found that that allows for good flow of fluid while keeping that critical threshold of 30 millimeters of mercury well out of the way. It's easier to use an electronic pump system in order to control that. I find that to be a little easier.