Objective

To describe a combined ultrasound and endoscopic surgical technique for the minimally invasive treatment of Haglund's deformity and anterior calcifications of the Achilles tendon in chronic tendinopathy sequelae of partial rupture.

Materials And Methods

We present the case of a 57-year-old amateur runner with pain in the posterior region of the right foot associated with his sports activity. He has previously received open surgical treatment to perform an Achilles tendon shaving due to chronic degeneration caused by an old partial tear, without improving his symptoms. Over time, he has developed a Haglund's deformity, tendon calcifications and chronic bursitis, with fibrotic and poor- quality skin tissue. This scenario makes minimally invasive surgery a good option.With the patient in the prone position, we use the conventional posterolateral and posteromedial endoscopic portals, and two other accessories: a distal-posterolateral and distal-central-transtendinous portal. Begin by resecting the synovitis that these cases usually present with a shaver, using the posterolateral portal.Then, with a burr-type drill, we proceed to perform the resection of Haglund's exostosis from proximal to distal to the last insertional portion of the Achilles tendon. At this point the ultrasound assistance is crucial. It is essential and practical to change portals for a complete resection on both sides, and for optimal removal of the remaining bone debris from the procedure. Ultrasound assistance allows direct monitoring without radiation, with a margin of extreme precision of all the structures to be intervened, both bone and soft tissue, being especially helpful when resecting more anterior tendon calcifications.

Conclusions

This technique offers advantages mainly by caring for soft tissues when they are delicate, strict control of the Achilles tendon shaving. Live ultrasound allows us to safely guide to where the tendon changes from tendinopathic to healthy, minimizing damage and to perfectly identify Haglund's deformity thanks to the hyperechogenic reflectance of the cortical bone, making the use of intraoperative fluoroscopy unnecessary. These advantages, combined with endoscopic live vision, provide the ideal setting for complete resection of this deformity, providing a margin of safety for soft tissues. The disadvantages we found as it is an innovative technique, the coordination between the team (surgeon and sonographer) must be trained.