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Endoscopic Management of Retrocalcaneal Pain: a Prospective Observational Study

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Endoscopic Management of Retrocalcaneal Pain: a Prospective Observational Study International Journal of Research in Orthopaedics Meena MK et al. Int J Res Orthop. 2020 Jul;6(4):693-698 http://www.ijoro.org DOI: http://dx.doi.org/10.18203/issn.2455-4510.IntJResOrthop20202549 Original Research Article Endoscopic management of retrocalcaneal pain: a prospective observational study Mukesh Kumar Meena1, Mukesh Kalra1, Suryakant Singh1*, Sanjay Meena1, Vivek Jangira1, Dushyant Chouhan1, Neha Chaudhary2 1Department of Orthopaedics, Lady Hardinge Medical College and Associated Hospitals, New Delhi, India 2Department of Community and Family Medicine, All India Institute of Medical Sciences, Patna, Bihar, India Received: 19 May 2020 Revised: 03 June 2020 Accepted: 04 June 2020 *Correspondence: Dr. Suryakant Singh, E-mail: [email protected] Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. ABSTRACT Background: 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). Methods: 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. Results: 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. Conclusions: Endoscopic procedure for retrocalcaneal bursitis and Haglund deformity seemed to be a safe and efficacious option for surgical treatment of retrocalcaneal pain. Keywords: Non-insertional Achilles tendinosis, Retrocalcaneal bursitis, Haglund deformity, Endoscopic procedure INTRODUCTION enlargement on the posterosuperior border of the oscalcis and represents a painful heel condition caused by Retrocalcaneal pain, a common foot problem, may be due mechanically induced inflammation of the retrocalcaneal to retrocalcaneal bursitis, Haglund’s deformity, Achilles or supra calcaneal bursae, which become inflamed, tendonitis, or plantar fasciitis. Retrocalcaneal bursitis is a hypertrophied, and adherent to the underlying tendon.2,3 chronic debilitating condition characterized by pain which Dorsiflexion of the ankle revealed tenderness on either lies between the anterior aspect of the tendon and the side or anterior aspect of the tendoachilles. The lateral posterosuperior aspect of the calcaneum.1 Haglund’s view radiograph of the ankle joint shows posterosuperior deformity first described by Patrick Haglund is bony bony prominence and intra tendinous calcification that International Journal of Research in Orthopaedics | July-August 2020 | Vol 6 | Issue 4 Page 693 Meena MK et al. Int J Res Orthop. 2020 Jul;6(4):693-698 confirms the diagnosis. Various modalities of conservative were well padded, and the operative leg was supported on treatment have been recommended for retrocalcaneal pain, a pad to allow the foot to lie in a neutral position. The other including change of footwear, use of heel pads, moist heat, leg was lowered down approximately 20° compared to stretching exercises, local steroid injections, and operative leg (Figure 1). Dorsiflexion of the foot can be extracorporeal shock wave therapy.4-6 Surgery may be manipulated by placement of the surgeon’s body against indicated where conservative treatment fails. Several the foot. Thus, both hands were free to manipulate the methods of surgical treatment have been described arthroscope and the surgical instruments. previously including excision of the retrocalcaneal bursa, calcaneal osteotomy, and endoscopic decompression of a b the retrocalcaneal space.7-9 The study was done to evaluate the efficacy of arthroscopic decompression of retrocalcaneal bursa and posterosuperior bony spur. METHODS This prospective study was conducted in department of orthopaedics from September 2016 to March 2018. Ethical approval was obtained from the Institute Ethics Committee and written consent was taken from the participants after explaining the study purpose. 20 patients (26 heels), 14 females and 6 males were studied. Patient’s with history and physical examination suggestive of retrocalcaneal Figure 1 (a and b): Patient positioning. bursitis, Haglund deformity causing mechanical impingement, failure of conservative management (like One imaginary horizontal line from the tip of lateral modified footwear, non-steroidal anti-inflammatory malleolus to perpendicular to the Achilles tendon and two agents and physical therapy of 6-36 months) and Non- lines were drawn parallel to the medial and lateral border insertional Achilles tendinosis were included in the study. of Achilles tendon. The portals were made at the Patients suffering from marked calcified Achilles intersection point of these lines, inferior to the horizontal tendinosis, Infection, Insertional Achilles tendinosis, and line and lateral to the border of Achilles tendon Figure 2 (a having previous hind foot surgery were excluded from and b). The incision was slightly anterior to Achilles study. All Patients were evaluated with preoperative tendon and posterior to sural nerve. A blunt trocar was history, clinical examination, routine blood investigations, inserted through lateral incision. The 4 mm arthroscope and x-ray lateral view of calcaneum to fulfil inclusion (Stryker, San Jose, California) is introduced into this criteria. In cases of bilateral involvement only the heel formed space, which can be confirmed fluoroscopically. with more severe involvement was operated. Under direct vision a spinal needle is next introduced just medial to the Achilles tendon at approximately the same The patients were taken for the surgery after routine level as the lateral portal. The medial portal was similarly investigation and after obtaining anaesthetic fitness established just anterior to Achilles tendon. The medial towards surgery. The consent for surgery was also taken portal acted as working portal while the lateral portal was from the patient and attendants after explaining the used for visualisation (Stryker endoscopy video system procedure and possible complications. Limb was shaved and 30° scope). A 4.0 mm arthroscopic shaver was from knee to foot 1 day before the surgery. introduced into the medial portal (Figure 3) and the inflamed bursal tissue was removed. Once working space Scoring had been created to access the posterior calcaneus and Achilles tendon attachment. The American orthopaedic foot and ankle society (AOFAS) ankle-hindfoot scale was used to evaluate a b patients preoperatively and post-operatively at 3 weeks, 6 weeks and 6 months.10 The AOFAS score evaluates pain (40 points), function (50 points), and alignment (10 points). Operative technique The endoscopic procedure was performed with the patient in a prone position, with the foot hanging down the table, under spinal anaesthesia and tourniquet control after injection tetanus toxoid and antibiotics (injection ceftriaxone 1gm i/v and injection gentamicin 80mg i/v) were given 1 hour preoperatively. All bony prominences Figure 2 (a and b): Marking and making port. International Journal of Research in Orthopaedics | July-August 2020 | Vol 6 | Issue 4 Page 694 Meena MK et al. Int J Res Orthop. 2020 Jul;6(4):693-698 allowed for two weeks. However, all patients were instructed to elevate the foot as long as they are not mobile, at least for the first 5 days. Patients were allowed to walk with modified footwear for three months, followed by normal footwear. Complications of post-operative neuralgia and swelling and scar tenderness were noted in some patients. Statistical analysis Statistical analysis was performed using the statistical package for social sciences (SPSS) for windows, version 17.0. Continuous variables were presented as mean ±SD Figure 3: Surgical setting for retrocalcaneal and categorical variables were presented as absolute endoscopy. numbers and percentage. Continuous variables over time within the groups were analysed using repeated measures Depending on the quality of the bone, either the analysis of variance (ANOVA) followed by Bonferroni’s arthroscopic shaver or a 4.0 mm arthroscopic burr or both post hoc testing to compare the pre-operative and post- were used to re-sect the posterosuperior calcaneal operative scores (3 weeks, 6 weeks and 6 months). P≤0.05 prominence. Then a needle was inserted through the tendo was considered statistically significant. Achilles and visualized
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