Outcome of Endoscopic Calcaneoplasty in Insertional Achilles Tendinopathy with Retrocalcaneal Bursitis. A New Prospective Study.
Thinesh VS1, Gopinath M2, Michael DB1 and Abdul Rauf HA1
1Department of Orthopaedics, Hospital Tuanku Ja’afar Seremban, Malaysia
2Department of Orthopaedics, Hospital Port Dickson, Malaysia
Submission: August 29, 2016; Published: September 16, 2016
*Corresponding author: Thinesh VS, Registrar, Orthopedic Department, Hospital Tuanku Jaafar Seremban, Negeri Sembilan, Malaysia, Lot 474, Jalan Terisu, Batu 49, Kuala Terla, 39010 Cameron Highlands, Pahang, Malaysia, Tel:6012-5884656; Email:email@example.com
How to cite this article: Thinesh VS, Gopinath M, Michael DB, Abdul R H. Outcome of Endoscopic Calcaneoplasty in Insertional Achilles Tendinopathy with Retrocalcaneal Bursitis. A New Prospective Study.. Ortho & Rheum Open Access J. 2016; 2(5): 555596. DOI: 10.19080/OROAJ.2016.02.555596
Introduction: The aim of this study in to analyze the outcome of Endoscopic Calcaneoplasty Technique for the treatment of Insertional Achilles Tendinopathy with Retrocalcaneal Bursitis.
Methods: This prospective study consists of 6 patients (3 men, 3 women) with mean age of 44.3 years who were operated by a single surgeon from March to November 2014. The bone cutter shaver was used to remove sufficient amount of inflamed retrocalcaneal bursa and superior part of calcaneum under fluoroscopy guidance. All patients were discharged on the following day and allowed weight bearing as tolerated. American Orthopedic Foot and Ankle Society (AOFAS) score, SF-36 health survey score and Ogilvie-Harris score were documented at 3rd and 6th months follow up.
Results: All patients were followed up for at least 6 months. AOFAS scores showed significant improvement at 3rd and 6th months with p value of 0.028. SF-36 scores showed overall significant changes for physical functioning (p=0.04), physical role limitation (p=0.035), emotional wellbeing (
Conclusion: Endoscopic calcaneoplasty is a safe and effective technique for the treatment of Insertional Achilles Tendinitis with Retrocalcaneal Bursitis.
Keywords: Endoscopic; Calcaneoplasty; Achilles Tendinitis; Fluoroscopy; Bursa
Abbreviations: AOFAS: American Orthopedic Foot and Ankle Society; SF: Short Form; SPSS: Statistical Package for the Social Science; ESWT: External Shockwave Therapy
Achilles tendinopathy is a common hind foot disorder which affects both the active and non-active population. It’s occurence among Asians has shown an increasing trend due to their active involvement in sporting activities but limited literature is available documenting on Achilles tendinopathy. It can be classified as insertional and non- insertional tendinopathy . Insertinal tendinopathy is responsible for 20% to 25% of total Achilles tendon related disorders  and usually associated with retrocalcaneal bursitis. Insertional Achilles tendinopathy is a clinical syndrome consisting of pain, swelling and impaired performance. The pathology is located at the insertion of Achilles tendon on the postero-superior part of calcaneum and commonly associated with formation of bone spurs and calcifications of Achilles tendon.
Insertional Achilles tendinopathy is purely a clinical diagnosis. Patients presents with complaint of pain, appear at the beginning and ending of walking session, stiffness and
occasionally swelling of the hind foot. Examination findings include visible swelling, tenderness at postero-lateral aspect of the calcaneum and a palpable bony spur. Imaging like plain radiography and MRI can be used to support the diagnosis and exclude the differential diagnosis. Plain radiography may show ossification, a bone spur at the tendon’s insertion or radio-opacity of the retrocalcaneal recess. Meanwhile, MRI may reveal any bone formation or hyper intense signal at tendon insertion or retrocalcaneal recess.
The scientific evidence of the etiological factors is limited. The suggested pathophysiology is excessive loading during exercise or recurrent microtrauma leading to tendon damage
. The risk factors can be either intrinsic or extrinsic.
Intrinsic factors include tendon vascularity, gastrocnemiussoleus
dysfunction, age, gender, obesity, hypertension, diabetes
mellitus, dyslipidemia, pes cavus and lateral ankle instability
. Meanwhile, extrinsic factors are changes in training pattern,
poor technique, previous injuries, footwear and training on
hard, slippery or slanting surfaces [2,5].
This disorder is initially treated with non-operative
treatment. Patients are advised for complete or modified rest
and correction of possible intrinsic or extrinsic risk factors that
may contribute to pain. Adequate analgesia, local injection of
sclerosing agents, physiotherapy to strengthen the triceps surae
muscles and orthotic treatment like shoes change or heel lift
have shown some symptomatic improvement . McGarvey et
al.  have shown that 89% of their patients improved with nonoperative
Surgical intervention is recommended for failed nonoperative
treatment. The surgical principle involves removal
of the inflamed bursa, thickened synovium and resection of
postero-superior part of calcaneum. There are many surgical
options available such as open and endoscopic method with
good to excellent outcomes. A recent systematic review by
Wiegerinck et al.  has concluded that endoscopic surgery is
better compare to open intervention. This study is conducted
to analyze the outcomes of endoscopic calcaneoplasty in a
single operating centre within the Asian population. American
Orthopaedic Foot and Ankle Society (AOFAS) hind foot scoring
system, Short Form (SF 36) Health Survey and Ogilvie Harris
scores were used to evaluate the patient’s outcome.
This prospective study covers 9 patients (4 men, 5 women)
with mean age of 44.3 years who were operated by a single
surgeon from March to November 2014. Patients are selected
based on the criteria of failed conservative management for a
minimum of 4 months, declared fit for operation by anesthetist
and have given consent for operation. Persisting pain and
difficulty in walking were the main indications for operation.
History taking and examinations were repeated to establish
the diagnosis of Insertional Achilles Tendinopathy. Plain
radiography and MRI were done for all the patients to confirm
the diagnosis, exclude the differential diagnosis and ensure the
integrity of the Achilles tendon. Written consents were obtained
from all the patients for the operation. 3 patients refused surgery
just before the scheduled date due to social reasons.
All the operations were done under general anesthesia.
Prophylaxis dose of Intravenous Cefuroxime 1.5g was
given to the patient at the time of induction. The patients were
positioned prone with feet lying at the edge of the operating
table. The affected leg was raised slightly with rolled towel.
Area of interest was painted with Povidone Iodine and draped.
Thigh tourniquet was inflated after exsanguination of the leg
using crepe bandage. The degree of dorsiflexion of the foot is
manipulated by using the surgeon’s body against plantar surface
of the foot.
Endoscopic calcaneoplasty uses medial and lateral portals.
Lateral portal was created by making a small vertical skin incision
at the level of superior part of calcaneum lateral to Achilles
tendon. Blunt trocar was used to reach the retrocalcaneal space
and is replaced with 4.5-mm arthroscope shaft at the angle of
30°. Meanwhile, medial portal was created by using a spinal
needle as a guide at the superior part of calacaneum medial
to Achilles tendon. Stab incision was made and Kelly’s forceps
were used to reach the retrocalcaneal space. Bone cutter shaver
was introduced from medial portal and once placement was
confirmed by using arthroscopy, the inflamed bursa and superior
part of the calcaneum were removed using shaver. Sufficient
amout of calcaneum was removed by manipulating ankle joint
into dorsiflexion and plantarflexion position with the help of
fluoroscopy. Cutter surface of shaver was always placed facing
the calcaneum to protect the Achilles tendon .
The skin was closed with non-absorbable sutures and
compression dressing was done. All the patients were discharged
on the following day of operation after reviewing post-operative
plain radiographs. Patients were advised for range of motion
exercises and weight bearing as tolerated. Wounds were
inspected on day 3 and sutures were removed at 2 weeks. All
the patients were followed up at 1, 3 and 6 months following
The American Orthopaedic Foot and Ankle Society (AOFAS)
hind foot scoring system, Short Form (SF 36) Health Survey and
Ogilvie Harris scores were calculated pre- and postoperatively.
Each patient was assessed by two independent reviewers for
pre and postoperative scoring and average scores were taken for
each follow up. Patients also were asked whether will undergo
the same operation if his or her contralateral foot is affected.
Statistical Package for the Social Science (SPSS) was used to
analyze the data and calculate the p value.
All the patients were followed up for at least 6 months.
For each visit, all the patients were re-examined and assessed
for AOFAS Hind Foot Scoring, SF-36 scoring and Ogilvie Harris
scoring. Pre-operative and post-operative scores at 3 months
and 6 months were calculated and compared as shown in the
tables below (Tables 1-3). The AOFAS Hind Foot Scoring is based
pain (40 points), function (50 points) and alignment (10 points).
The mean AOFAS score improved from pre-operative score of
55.5 (range, 43-72) to post-operative score of 73.0 (Range, 55-
84) at 3 months and 79.5 (range, 69-88) at 6 months. Wilcoxon
signed rank analysis showed significant AOFAS scores with p
values of 0.028 at 3 months and 6 months. Only one out of six patients had daily pain at 6 months follow up and could be due
to scar tenderness.
The SF-36 Health Survey evaluates 8 parameters with the
scores ranging from minimum of 0 to maximum of 100. Based
on repeated measure ANOVA, average scores of SF-36 showed
significant changes for physical functioning (p=0.04), physical
role limitation (p=0.035), emotional wellbeing (p=0.005) and
Ogilvie Harris scoring is based on clinical assessment with
maximum score of 16. The results were scored as excellent (15 to
16 points), good (13 to 14 points) or unsatisfactory (<13 points).
At 6 months follow up, 4 patients had excellent results, one had
good result and one had unsatisfactory result. 5 out of 6 patients
agreed for the same operation if contralateral foot is affected.
All the wounds healed well and no incidence of infection was
reported. Although all patients had improvement in all scores
evaluated as compared to preoperative scores, one patient has
persistent scar tenderness (Figures 1 & 2).
Insertional Achilles Tendinopathy can be treated with or
without operation and choice of treatment depends on patients.
Non-active patients may choose non-operative treatment for a
period of 4 to 6 months before deciding for operative treatment.
Meanwhile, active patients like professional sportsman may
directly opt for operation without non-operative treatment for
early return to sports and work. A wide range of non-invasive
and non-operative methods have been developed and modified
to treat Insertional Achilles Tendinopathy. However, the success
rate is inconclusive due to insufficient clinical evidence .
Surgical options are offered for failed non-operative treatment.
Open and minimal invasive surgeries have shown excellent
results but minimal invasive surgeries are gaining popularity
among patients due to early work and sport resumption .
Non-operative treatment includes adequate rest of the
Achilles tendon from excessive load and gradual muscle exercise
to build the strength of the triceps surae muscles . Patients
are advised to avoid tight shoes and improvise their techniques
in work and sporting activities [6,13]. Non-steroidal antiinflammatory
drugs have only analgesic effect without any long
term benefit [6,13]. Corticosteroid injections are being offered
to patients by some centers but the safety of its usage in our
center is outweighed by the complications. Adverse effects of
using corticosteroid includes reduce strength of the tendon,
thus precipitate tendon rupture . None of the patients in our
center was given corticosteroid injection. External shockwave
therapy (ESWT) have shown high success rate when combined
with eccentric exercises. Vulpiani et al. 2009 have concluded that
ESWT has positive effect on the treatment of tendinopathy with
long lasting improvement of pain .
Surgical options for Insertional Achilles Tendinopathy have
changed tremendously in the past decade due to advancement
of technology and increased social needs of patients. It can
be divided into open and minimal invasive surgeries. Open
calcaneoplasty used to be the gold standard of surgical
interventions until minimal invasive surgery become available.
Many literatures have reported the good outcome of open
surgery. However, open surgeries are highly invasive, associated
with many complications and patients need longer recovery
time. Common complications associated with open surgery are
surgical site infection, wound dehiscence, bad scars and rupture
of Achilles tendon [16-18].
Study conducted by Chen CH et al.  on 19 patients (30
heels) who underwent excision of the posterior calcaneal
tuberosity and bursectomy through a medial longitudinal
incision with average follow up period of 6 years, 10% of the
patients had persistent pain and 83% had residual pain for
half to two years after operation. Meanwhile, Angermann et
al.  reported the outcome on 40 patients (40 heels) who
were managed by resection of the posterosuperior aspect of
calcaneum through posterolateral approach. Results after an
average of 6 years showed 50% of heels recovered, 20% were
improved and 10% were worse among 37 patients who were
allowed immediate weight bearing. Documented complications
include one superficial heel infection, one hematoma and two
cases of delay wound healing.
Advantages of endoscopic technique over open surgeries
are short recovery time, rapid return to work and sports, small
incision and good scar healing . Van Dijk et al.  reported
endoscopic calcaneoplasty in 2001. In this study, endoscopic
calcaneoplasty was performed in 20 patients (21 heels). The
average follow up was 3.9 years and one patient had fair result,
4 patients had good results and the remaining 15 patients had
excellent results. Most of these cases are same day surgery and
patients do not need to stay overnight. There were no surgical
and post-operative complications. All the patients had short
recovery time and quickly back to work and sports. Systematic
review on surgical treatment of chronic retrocalcaneal bursitis
has reported 12 open surgical technique trials and 3 endoscopy
technique studies evaluating 547 procedures in 461 patients
. Patient satisfaction and complication rate favored
Studies reporting the outcome of endoscopic calcaneoplasty
among Asian populations with Insertional Achilles Tendinopathy
are very limited. Late presentations to hospital among Asians
due to higher pain threshold and tendency to try out traditional
treatment may affect the outcome of endoscopy calcaneoplasty.
This study has shown a good outcome and can be used as
reference for future research with larger sample size and longer
follow up durations.
Endoscopic calcaneoplasty is a safe and effective surgery for
Insertional Achilles Tendinopathy with Retrocalcaneal Bursitis
providing right techniques are used and done by qualified
surgeons. The significant advantages are early return to work
and sports due to quick postoperative recovery with minimal
rehabilitation, small incision, cosmetically acceptable scar and