Functional evaluation of patients undergoing endoscopic calcaneoplasty for Haglund deformity

Objective: To analyze the functional outcomes of patients undergoing endoscopic calcaneoplasty for the treatment of Haglund deformity. Methods: This study consists of a case series of patients undergoing endoscopic calcaneoplasty. The American Orthopaedic Foot and Ankle Society ankle-hindfoot scale, was used to evaluate patients before and 12 months after the procedure, providing preoperative and postoperative scores. Results: Nineteen patients were evaluated for a total of 24 endoscopic calcaneoplasties. The American Orthopaedic Foot and Ankle Society scale provided a mean preoperative score of 31.4 and a mean postoperative score of 93.3, which shows a significantly increased score after surgery. The mean patient age was 52 years, and the youngest patient was 25 years old and the oldest patient was 73 years old. However, no significant relationship was found between age and change in the American Orthopaedic Foot and Ankle Society score. No complications were observed in the immediate or late postoperative periods. Conclusion: Arthroscopic resection is efficient in the treatment of Haglund deformity given the significant improvement in the American Orthopaedic Foot and Ankle Society score observed after the procedure. Also, no postoperative complications were seen in patients who underwent endoscopic calcaneoplasty. Level of Evidence: IV; Therapeutic Studies; Case series.

Return to Play After Open Calcaneoplasty for Insertional Achilles Tendinopathy With Haglund Deformity in Competitive Professional Athletes

Background: Surgical treatment of insertional Achilles tendinopathy with Haglund deformity in highly competitive professional athletes has not been previously investigated. Purpose: To assess clinical outcomes, including return to play (RTP), after surgical treatment of insertional Achilles tendinopathy in professional athletes. Study Design: Case-control study; Level of evidence, 3. Methods: This retrospective study included 20 professional athletes who were surgically treated for insertional Achilles tendinopathy and had at least 2 years of follow-up. An open longitudinal lateral approach was used for the operation, without violation of the Achilles tendon. Outcome evaluation included American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score, subjective patient satisfaction, mean time of return to competition (RTC), and rate of RTP. We defined RTC as return to an official match for at least 1 minute and RTP rate as the percentage of patients who were able to participate in at least 2 full seasons. A subgroup analysis was performed to compare the RTP and no-RTP groups. Results: The AOFAS score improved significantly from preoperatively to the final follow-up (from 65.1 to 88.4; P < .001), and 75% of the patients reported good to excellent satisfaction. The mean time of RTC was 7.45 months (range, 4-18 months), and the rate of RTP was 60%. The RTP group had a significantly lower mean body mass index than did the no-RTP group (22.03 vs 23.86, respectively; P = .005) and faster mean RTC (5.0 vs 11.1 months, respectively; P < .001). Conclusion: Open calcaneoplasty for surgical treatment of insertional Achilles tendinopathy with Haglund deformity in highly competitive professional athletes should be approached cautiously. Our patients had a 7.5-month recovery period before return to their first official match, and only 60% of the patients returned to their sports activity and participated in at least 2 full seasons. Lower body mass index and a faster RTC after surgery were related to longer functional maintenance.

Achilles tendon detachment after local infiltration of corticosteroids

Complete disinsertion of the Achilles tendon is relatively rare but is an injury of considerable clinical significance. A 50-year-old non-smoking man presented with complete disinsertion of the Achilles tendon due to an indirect low-energy trauma shortly after administration of local corticosteroid injections (LCI) for treatment of deep retrocalcaneal bursitis. Imaging studies showed complete disinsertion of the Achilles tendon as well as severe Haglund syndrome and retrocalcaneal bursitis. The tendon was repaired, and the Haglund deformity and retrocalcaneal bursa were then resected. Although Achilles tendon rupture is a frequent complication after LCI, to date, no cases of disinsertion have been published. Surgeons must be aware of this issue, especially in patients with previous insertional calcific Achilles tendinosis and Haglund syndrome. Level of Evidence V; Therapeutic Studies; Expert Opinion.

Acute-Onset Achilles Tendon Pain and Swelling Treated with an Amniotic Fluid–Derived Allograft: A Case Study

Background Tendinopathies are common musculoskeletal disorders that often develop because of chronic loading and failed healing. Tendinopathy related to systemic inflammation has been less extensively examined. Furthermore, although the use of biological agents to treat tendinopathies continues to gain popularity, the use of amniotic fluid–derived allografts in outpatient settings to resolve tendinopathies requires further evaluation. Methods The focus of this case report is a 25-year-old man who presented for a second opinion, having been diagnosed with Haglund deformity and Achilles tendinopathy. At the time of presentation, he complained of 10 of 10 pain to the right Achilles tendon. He was treating the injury conservatively with intermittent use of a controlled ankle motion boot and working with physiotherapy for approximately 5 months before presentation. Diagnostic ultrasound along with magnetic resonance imaging indicated distal thickening of the Achilles tendon, substantial fluid and edema in the Kager fat pad, and retrocalcaneal erosions with bursitis. Conservative management did not resolve the symptoms. As an alternative to surgery, the patient elected to undergo an Achilles tendon injection of an amniotic fluid–derived allograft. Before and after the initial injection, a microdialysis catheter was inserted into the Achilles peritendinous space to sample local levels of extracellular matrix enzymes and growth factors important for tendon remodeling. The patient received considerable relief with the initial injection, but did not return to full strength. Over the subsequent 8 weeks, the patient was followed closely and was able to return to daily activities with minimal pain. He was not able to return to a more active lifestyle without further Achilles pain, so a second amniotic fluid–derived allograft injection was performed 8 weeks after the initial injection. Results Injection of the initial allograft resulted in significant improvement, but not complete resolution of pain and swelling. Microdialysis findings suggested a reduction in peritendinous levels of the cytokine interlukin-6 in addition to changes in extracellular matrix regulatory enzymes. After 8 weeks of additional conservative therapy and a second injection, no further improvement in pain was noted. Conclusions Based on the clinical improvement of symptoms in this individual and the changes seen with microdialysis methodology, the authors find the use of amniotic fluid–derived allograft injection for treatment of Achilles pain in this patient to be a viable treatment. Additional comorbidities of systemic inflammatory polyarthritis and possible seronegative disease were addressed after rheumatology consultation with a variety of medications that provided the patient additional relief of his symptoms. The patient ultimately moved and was lost to further follow-up.

A Narrative Review of the Classification and Use of Diagnostic Ultrasound for Conditions of the Achilles Tendon

Enthesitis is a cardinal feature of spondyloarthropathies. The Achilles insertion on the calcaneus is a commonly evaluated enthesis located at the hindfoot, generally resulting in hindfoot pain and possible tendon enlargement. For decades, diagnosis of enthesitis was based upon patient history of hindfoot or posterior ankle pain and clinical examination revealing tenderness and/or enlargement at the site of the tendon insertion. However, not all hindfoot or posterior ankle symptoms are related to enthesitis. Advanced imaging, including magnetic resonance imaging (MRI) and ultrasound (US), has allowed for more precise evaluation of hindfoot and posterior ankle conditions. Use of US in diagnosis has helped confirm some of these cases but also identified other conditions that may have otherwise been misclassified without use of advanced imaging diagnostics. Conditions that may result in hindfoot and posterior ankle symptoms related to the Achilles tendon include enthesitis (which can include retrocalcaneal bursitis and insertional tendonopathy), midportion tendonopathy, paratenonopathy, superficial calcaneal bursitis, calcaneal ossification (Haglund deformity), and calcific tendonopathy. With regard to classification of these conditions, much of the existing literature uses confusing nomenclature to describe conditions in this region of the body. Some terminology may imply inflammation when in fact there may be none. A more uniform approach to classifying these conditions based off anatomic location, symptoms, clinical findings, and histopathology is needed. There has been much debate regarding appropriate use of tendonitis when there is no true inflammation, calling instead for use of the terms tendinosis or tendonopathy. To date, there has not been clear examination of a similar overuse of the term enthesitis in conditions where there is no underlying inflammation, thus raising the need for more comprehensive taxonomy.

Semi-automatic Software-based 3D-Angular Measurement For Weight-Bearing CT (WBCT) is 97% Faster than Measurement by Hand and Provides Similar Angles

Category: Basic Sciences/Biologics Introduction/Purpose: Weight-bearing CT (WBCT) has been proven to allow for more precise and valid measurement of bone position (angles) than conventional weight-bearing radiographs (R) and conventional CT without weight-bearing (CT)1. The measurement by hand (MBH) has demonstrated adequate inter- and intraobserver reliability but high time consumption1. Recently, a semi-automatic software-based angular measurement (SAM) has been developed (Disior Ltd, Helsinki, Finland). The purpose of this study was to compare SAM with MBH regarding angles values and time spent for the investigator. Methods: Fifteen bilateral WBCT scans (PedCAT, Curvebeam, Warrington, PA, USA) were randomly extracted from a local institutional database with more than 13,000 scans. Nineteen angles as shown in table 1 were measured with MBH as previously described and with SAM1. SAM includes software generated 3D models with semi-automatic bone specification of tibia, fibula, talus, calcaneus, navicular, cuboid, cuneiforms and metatarsals. The software automatically defines the longitudinal axes of these bones and automatically measures the angles between these axes. The time spent of the investigator for the measurements was recorded (total process MBH and specification of bones for SAM). The software calculation time for SAM was not measured or considered as investigator time spent. The angles and time spent of MBH and SAM were compared (t-test, homoscedatic). Results: Mean age of the subject was 58 years (range, 7-81), 12 (40%) were male. The pathologies were bilateral in 8 (54%), right in 4 (27%) and left in 3 (20%) subjects (23 feet in total) and were specified as follows, ankle osteoarthritis/instability in 6 (26%), Haglund deformity/Achillodynia in 4 (17%), Forefoot deformity in 7 (30%), Charcot arthropathy in 2 (9%), flatfoot in 4 (17%) feet. The angles did not differ between MBH and SAM (Table 1, each p>.05). The time spent for MBH / SAM was 780+-171s / 20+-8 s on average in total for 19 angles and 41+-9s / 1+-0.4 s per angle (p<.01). Conclusion: This is the first study comparing MBH with SAM. SAM shows similar angles as MBH and can be also considered as reliable measurement option. The investigator time spent is 97% lower for SAM (1 s per angle) than for MBH (41 s per angle). SAM is an important step forward for 3D-angle measurement of WBCT. The next desired is fully automatic software-based measurement. References1. Richter M, Seidl B, Zech S, Hahn S. PedCAT for 3D-Imaging in Standing Position Allows for More Accurate Bone Position (Angle) Measurement than Radiographs or CT. Foot Ankle Surg 2014;20:201-7. [Table: see text]

Endoscopic management of retrocalcaneal pain: a prospective observational study

<p class="abstract"><strong>Background:</strong> In an effort to reduce morbidity and complications of open surgery, an endoscopic technique was used for the management of the conditions leading to retrocalcaneal pain. With this purpose, the current study was undertaken to evaluate results of endoscopic management of retrocalcaneal pain using American orthopaedic foot and ankle score (AOFAS).</p><p class="abstract"><strong>Methods:</strong> 20 patients (26 heels) in the age group 18-80 years presenting with retrocalcaneal pain not responding to conservative management underwent endoscopic decompression of the retrocalcaneal bursae and excision of bony spurs. Two portals were created, one laterally and one medially, over the posterosuperior portion of the calcaneus to gain access to the retrocalcaneal space. The inflamed bursal tissue was identified and removed, and the prominent bone was resected. The functional outcome was evaluated pre and postoperatively with the AOFAS.<strong></strong></p><p class="abstract"><strong>Results:</strong> 70% patients have retrocalcaneal bursitis, 20% Haglund’s deformity as confirmed on lateral view of ankle X-ray and only 10% of non-insertional tendinosis. Mean operative time was 54.95 minutes. Mean duration of hospital stay was 3.90±0.64 and the mean follow-up was 66 days (range 30-180 days). The average AOFAS score improved from 65.60 points pre-operatively to 96.80 points at final follow-up. There were fifteen excellent results, seven good results, two fair results and two poor results.</p><p class="abstract"><strong>Conclusions:</strong> Endoscopic procedure for retrocalcaneal bursitis and Haglund deformity seemed to be a safe and efficacious option for surgical treatment of retrocalcaneal pain.</p>