Retrocalcaneal Bursitis - A Complete Guide

const pptxgen = require("pptxgenjs");
const { execSync } = require("child_process");

// ── Fetch all images ──────────────────────────────────────────────────────────
const imageUrls = [
  "https://cdn.orris.care/cdss_images/2552b51a06c8a672790c07de779e7740ecda895a9121397a5dbe9030ffd1be7b.png", // Haglund X-ray
  "https://cdn.orris.care/cdss_images/9b682c75f07ccfac7ba9b8d23ff7c9904f583b6b7c2192404d29d8fc94b2e094.png", // MRI Haglund syndrome triad
  "https://cdn.orris.care/cdss_images/719c92d190cc775d327fad8c132f988df02c80348f8743f56d24d142ed9b3d16.png", // Pre/intraop radiograph
  "https://cdn.orris.care/cdss_images/c77cd37ed2dea1c94a909acb623717a5af67bc5cdfce3b60828ec6eef9b15dd8.png", // Ultrasound Achilles
];

const imgs = JSON.parse(
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  ).toString()
);

const [imgXray, imgMRI, imgIntraop, imgUS] = imgs.map(i => i.base64);

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// ── Presentation setup ────────────────────────────────────────────────────────
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pres.title  = "Retrocalcaneal Bursitis - Complete Guide";
pres.author = "Orris Medical";

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// ══════════════════════════════════════════════════════════════════════════════
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// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 2 — TABLE OF CONTENTS
// ══════════════════════════════════════════════════════════════════════════════
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    ["2", "Pathophysiology & Haglund Deformity", "रोगनिर्मिती"],
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    ["4", "Imaging (X-ray, US, MRI)", "प्रतिमाशास्त्र"],
    ["5", "Differential Diagnosis", "विभेदक निदान"],
    ["6", "Non-operative Management", "शस्त्रक्रियारहित उपचार"],
    ["7", "Operative Management", "शस्त्रक्रिया उपचार"],
    ["8", "Radiological Measurements", "रेडिओलॉजिकल मोजमाप"],
    ["9", "Endoscopic Surgery & Outcomes", "दुर्बीण शस्त्रक्रिया"],
    ["10", "Physical Therapy Protocol", "भौतिक चिकित्सा"],
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// ══════════════════════════════════════════════════════════════════════════════
// SECTION DIVIDER — ANATOMY
// ══════════════════════════════════════════════════════════════════════════════
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// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 3 — ANATOMY
// ══════════════════════════════════════════════════════════════════════════════
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  slideTitle(s, "Anatomy of the Retrocalcaneal Bursa", "रेट्रोकॅल्केनियल बर्साची शरीररचना");

  // Left column — text
  s.addText([
    ...bullet("Synovial bursa located DEEP to Achilles tendon", "अकिलीस कंडराच्या खाली असलेली सायनोव्हियल पिशवी"),
    ...bullet("Between Achilles tendon & posterosuperior calcaneal tuberosity", "अकिलीस कंडरा व कॅल्केनियसच्या वरच्या मागील बाजूमध्ये"),
    ...bullet("Part of the Achilles Entheseal Organ:", "अकिलीस एन्थेसल ऑर्गनचा भाग:"),
    ...bullet("→ Fibrocartilage on anterior tendon surface", "", 1),
    ...bullet("→ Fibrocartilage on calcaneal surface", "", 1),
    ...bullet("→ Retrocalcaneal bursa (space between)", "", 1),
    ...bullet("→ Kager's fat pad (synovial-lined, slides in/out with ankle motion)", "कागरचा फॅट पॅड", 1),
    ...bullet("→ Underlying trabecular bone", "", 1),
    ...bullet("Prime enthesitis site in Spondyloarthropathy (SpA)", "स्पॉन्डिलोआर्थ्रोपॅथीमध्ये प्रमुख ठिकाण"),
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    "Retrocalcaneal Bursa (Deep)  |  रेट्रोकॅल्केनियल बर्सा (खोल)",
    "Between Achilles tendon and posterosuperior calcaneus.\nClinically more significant.\nAffected in Haglund syndrome & SpA.",
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  infoBox(s, bx, 3.5, 5.7, 1.6,
    "Retroachilles Bursa (Superficial)  |  रेट्रोअकिलीस बर्सा (वरवरची)",
    "Between Achilles tendon and overlying skin.\nIrritated by stiff shoe heel counters.\nAlso called pre-tendinous / subcutaneous bursa.",
    C.orange
  );

  infoBox(s, bx, 5.2, 5.7, 1.85,
    "Systemic Associations  |  प्रणालीगत कारणे",
    "• Spondyloarthritis (SpA) — prime entheseal site\n• Rheumatoid Arthritis (RA)\n• Gout — urate crystal deposition\n• CPPD disease\n• Ochronosis (homogentisic acid)\n• Fluoroquinolone-induced tendinopathy",
    C.red
  );
}

// ══════════════════════════════════════════════════════════════════════════════
// SECTION DIVIDER — PATHOPHYSIOLOGY
// ══════════════════════════════════════════════════════════════════════════════
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// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 4 — PATHOPHYSIOLOGY + HAGLUND X-RAY
// ══════════════════════════════════════════════════════════════════════════════
{
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    { text: "Haglund Deformity", options: { bold: true, color: C.gold, fontSize: 14, breakLine: true } },
    { text: "हॅग्लंड विकृती", options: { italic: true, color: C.accent, fontSize: 12, breakLine: true } },
    { text: " ", options: { fontSize: 6, breakLine: true } },
    { text: "• Large exostosis off posterosuperior calcaneal tuberosity (ANTERIOR to Achilles tendon)\n", options: { color: C.white, fontSize: 12 } },
    { text: "• Repeated dorsiflexion → tendon abraded against tuberosity\n", options: { color: C.white, fontSize: 12 } },
    { text: "• Chronic microtrauma → bursal inflammation\n", options: { color: C.white, fontSize: 12 } },
    { text: "• Prolonged inflammation → degenerative changes + osteophytes\n\n", options: { color: C.white, fontSize: 12 } },
    { text: "Cascade of Events  |  घटनाक्रम:\n", options: { bold: true, color: C.gold, fontSize: 13, breakLine: true } },
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    ["Mechanical Impingement", "यांत्रिक दाब", C.teal],
    ["Bursal Inflammation", "बर्साची जळजळ", C.red],
    ["Tendinosis + Osteophytes", "टेंडिनोसिस + अस्थिवृद्धी", C.mgray],
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  // Right side — X-ray image
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    s.addImage({ data: imgXray, x: 5.4, y: 1.0, w: 7.5, h: 5.8 });
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  s.addText("Lateral Heel X-ray: Haglund deformity (box) + Insertional Achilles Spur (arrow)\nपार्श्व टाच क्ष-किरण: हॅग्लंड विकृती (चौकट) + अकिलीस स्पर (बाण)", {
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// ══════════════════════════════════════════════════════════════════════════════
// SECTION DIVIDER — CLINICAL PRESENTATION
// ══════════════════════════════════════════════════════════════════════════════
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}

// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 5 — CLINICAL PRESENTATION
// ══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  addLightBg(s);
  slideTitle(s, "Clinical Presentation", "नैदानिक सादरीकरण — लक्षणे व चिन्हे");

  // Symptoms box
  infoBox(s, 0.4, 1.15, 6.0, 2.8,
    "Symptoms  |  लक्षणे",
    "• Deep posterior heel pain (खोल मागील टाचदुखी)\n• Insidious onset — NOT acute\n• Morning pain / stiffness on first steps\n  (सकाळी पहिल्या पावलांवर वेदना)\n• Worse with ankle dorsiflexion\n  (घोट्याच्या वरच्या दिशेने हालचालीत वाढते)\n• Difficulty wearing closed-back shoes\n  (बंद टाचेचे शूज घालण्यात अडचण)\n• Visible posterior heel swelling / bony bump",
    C.teal
  );

  // Signs box
  infoBox(s, 0.4, 4.1, 6.0, 2.85,
    "Physical Signs  |  शारीरिक चिन्हे",
    "• Mediolateral tenderness ANTERIOR to Achilles tendon\n  (अकिलीस कंडराच्या आधी मध्य-पार्श्व कोमलता)\n• Fluid fluctuation test (द्रव चाचणी):\n  Thumb + index finger on each side of tendon;\n  other index presses over tendon → perceive fluctuation\n• Palpable Haglund bony prominence\n• Gastrosoleus contracture on exam\n  (गॅस्ट्रोसोलियस आकुंचन)\n• Increased pain with passive dorsiflexion",
    C.orange
  );

  // Key Distinction box
  infoBox(s, 6.65, 1.15, 6.25, 2.0,
    "Key Clinical Distinction  |  महत्त्वाचा फरक",
    "Pain on FIRST ARISING in morning\n→ Retrocalcaneal bursitis / Achilles tendinopathy\n\nPain ONLY WITH SHOES\n→ Pretendinous (superficial) bursitis",
    C.navy
  );

  // Warning box fluoroquinolone
  infoBox(s, 6.65, 3.3, 6.25, 1.8,
    "⚠  Fluoroquinolone Warning  |  सावधान",
    "Ciprofloxacin / Levofloxacin can cause Achilles\ntendinopathy ± rupture — during or weeks AFTER use.\nIMPORTANT: Stop drug immediately if recognised!\n(फ्लुरोक्विनोलोन चालू असताना अकिलीस कंडरा फुटण्याचा धोका)",
    C.red
  );

  // Haglund syndrome triad
  s.addShape(pres.shapes.RECTANGLE, {
    x: 6.65, y: 5.2, w: 6.25, h: 1.75,
    fill: { color: "EAF6FF" }, line: { color: C.teal, width: 1 }
  });
  s.addText("Haglund Syndrome Triad  |  हॅग्लंड सिंड्रोम त्रिकूट", {
    x: 6.75, y: 5.25, w: 6.05, h: 0.32,
    fontSize: 12, bold: true, color: C.navy, fontFace: "Calibri", margin: 0
  });
  s.addText(
    "1. Insertional Achilles Tendinopathy\n2. Retrocalcaneal Bursitis\n3. Posterosuperior Calcaneal Exostosis (Haglund deformity)",
    { x: 6.75, y: 5.6, w: 6.05, h: 1.2, fontSize: 11.5, color: C.navy, fontFace: "Calibri" }
  );
}

// ══════════════════════════════════════════════════════════════════════════════
// SECTION DIVIDER — IMAGING
// ══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  sectionDivider(s, "04", "Imaging", "प्रतिमाशास्त्र — क्ष-किरण, अल्ट्रासाउंड, MRI", C.accent);
}

// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 6 — X-RAY + MEASUREMENTS
// ══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  addSplitBg(s, C.offwht, C.navy, 6.9);
  slideTitle(s, "Plain Radiograph — Lateral Heel X-ray", "पार्श्व टाच क्ष-किरण");

  s.addText([
    ...bullet("Standing lateral view — FIRST-LINE imaging", "उभे राहून पार्श्व दृश्य — प्रथम पसंती"),
    ...bullet("Shows: Haglund deformity, insertional spur, calcification", "दाखवते: हॅग्लंड विकृती, स्पर, कॅल्सिफिकेशन"),
    { text: "\nRadiological Measurements  |  रेडिओलॉजिकल मोजमाप:\n", options: { bold: true, color: C.navy, fontSize: 13, fontFace: "Calibri", breakLine: true } },
    ...bullet("Fowler-Philip Angle: >75° = abnormal (normal <69°)", "फॉलर-फिलिप कोन: >७५° = असामान्य"),
    ...bullet("Parallel Pitch Lines (PPL): calcaneal process projects above upper line = Haglund", "समांतर पिच रेषा"),
    ...bullet("Calcaneal Pitch Angle: ↑ angle associated with insertional tendinopathy", "कॅल्केनियल पिच कोन"),
    { text: "\n⚠ Caveat:", options: { bold: true, color: C.red, fontSize: 12, fontFace: "Calibri", breakLine: true } },
    ...bullet("Haglund size is NOT statistically different between symptomatic patients and controls!", "हॅग्लंड आकार आणि लक्षणे यांचा थेट संबंध नाही!"),
    ...bullet("Insertional osteophyte + calcaneal pitch angle have stronger association", ""),
  ], {
    x: 0.4, y: 1.15, w: 6.2, h: 6.1,
    fontSize: 12, color: C.navy, fontFace: "Calibri", valign: "top"
  });

  // X-ray image on right
  if (imgXray) {
    s.addImage({ data: imgXray, x: 7.1, y: 0.9, w: 5.9, h: 5.6 });
  }
  s.addText("Haglund deformity (box) + Insertional Achilles spur (arrow)\nहॅग्लंड विकृती (चौकट) + अकिलीस स्पर (बाण)\nSource: Campbell's Operative Orthopaedics 15th Ed", {
    x: 7.1, y: 6.52, w: 5.9, h: 0.65,
    fontSize: 9, color: C.lgray, italic: true, fontFace: "Calibri", align: "center"
  });
}

// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 7 — MRI IMAGING
// ══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  addLightBg(s);
  slideTitle(s, "MRI & Ultrasound Imaging", "MRI व अल्ट्रासाउंड प्रतिमाशास्त्र");

  // MRI image
  if (imgMRI) {
    s.addImage({ data: imgMRI, x: 0.4, y: 1.1, w: 4.5, h: 5.6 });
  }
  s.addText("Sagittal PD fat-sat MRI — Haglund Syndrome:\nInsertional tendinopathy (→), Retrocalcaneal bursitis (short →), Haglund exostosis (*)\nसॅजिटल MRI: हॅग्लंड सिंड्रोम त्रिकूट\nSource: Grainger & Allison's Diagnostic Radiology", {
    x: 0.4, y: 6.72, w: 4.5, h: 0.65,
    fontSize: 8.5, italic: true, color: C.mgray, fontFace: "Calibri", align: "center"
  });

  // Ultrasound image
  if (imgUS) {
    s.addImage({ data: imgUS, x: 5.1, y: 1.1, w: 4.2, h: 5.0 });
  }
  s.addText("Ultrasound: Achilles tendinopathy (*) with retrocalcaneal bursitis\nDoppler = new vessel formation\nअल्ट्रासाउंड: अकिलीस टेंडिनोपॅथी + रेट्रोकॅल्केनियल बर्सायटिस\nSource: Grainger & Allison Radiology", {
    x: 5.1, y: 6.12, w: 4.2, h: 0.78,
    fontSize: 8.5, italic: true, color: C.mgray, fontFace: "Calibri", align: "center"
  });

  // MRI vs US comparison
  infoBox(s, 9.55, 1.1, 3.35, 2.5,
    "MRI Indications  |  MRI कधी?",
    "• Quantify tendinosis extent\n• Rule out partial tear\n• Pre-op: confirm <50% tendinosis\n  (for Zadek osteotomy)\n• Rarely needed for diagnosis alone\n  (निदानासाठी क्वचितच लागते)",
    C.teal
  );
  infoBox(s, 9.55, 3.75, 3.35, 2.5,
    "Ultrasound Advantages  |  US फायदे",
    "• Real-time, dynamic imaging\n• Cheap & widely available\n• Bursal fluid (anechoic collection)\n• Doppler: hyperaemia in active\n  inflammation\n• No radiation\n  (रेडिएशन नाही)",
    C.green
  );
}

// ══════════════════════════════════════════════════════════════════════════════
// SECTION DIVIDER — DIFFERENTIAL DIAGNOSIS
// ══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  sectionDivider(s, "05", "Differential Diagnosis", "विभेदक निदान", C.red);
}

// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 8 — DIFFERENTIAL DIAGNOSIS TABLE
// ══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  addLightBg(s);
  slideTitle(s, "Differential Diagnosis of Posterior Heel Pain", "मागील टाचदुखीचे विभेदक निदान");

  const rows = [
    ["Condition", "Key Feature", "Distinguishing Sign", "Treatment Difference"],
    ["Retrocalcaneal Bursitis\n(रेट्रोकॅल्केनियल बर्सायटिस)", "Deep, anterior to Achilles", "Mediolateral fluctuation test +ve", "Avoid steroid near tendon"],
    ["Insertional Achilles\nTendinopathy", "Midline tenderness at insertion", "Tender directly OVER tendon", "Eccentric loading"],
    ["Pretendinous Bursitis\n(वरवरची बर्सायटिस)", "Pain ONLY with closed-back shoes", "Superficial, posterior to tendon", "Shoe modification"],
    ["Plantar Fasciitis\n(प्लांटर फॅसिटिस)", "Plantar heel, worst first step", "Medial calcaneal tubercle tender", "Plantar stretch"],
    ["Sever's Disease\n(मुलांमध्ये - सेव्हर आजार)", "Children 7-10 yrs, activity pain", "Posterior heel apophysis tender", "Rest, self-limiting"],
    ["Gout / CPPD\n(गाउट)", "Acute attack, red hot joint", "Serum uric acid ↑, crystals", "Colchicine / NSAIDs"],
    ["Spondyloarthropathy\n(स्पॉन्डिलोआर्थ्रोपॅथी)", "Bilateral, systemic features", "HLA-B27, bilateral enthesitis", "DMARDs / biologics"],
    ["Achilles Tendon Rupture\n(फाटलेला कंडरा)", "Acute onset, pop felt", "Thompson test +ve, palpable gap", "Surgery / boot"],
  ];

  const colW = [3.0, 2.8, 3.3, 3.7];
  const colX = [0.3, 3.35, 6.2, 9.55];
  const rowH = 0.56;
  rows.forEach((row, ri) => {
    row.forEach((cell, ci) => {
      const isHeader = ri === 0;
      s.addShape(pres.shapes.RECTANGLE, {
        x: colX[ci], y: 1.15 + ri * rowH, w: colW[ci], h: rowH,
        fill: { color: isHeader ? C.teal : ri % 2 === 0 ? C.white : "EDF3F8" },
        line: { color: C.lgray, width: 0.5 }
      });
      s.addText(cell, {
        x: colX[ci] + 0.08, y: 1.18 + ri * rowH, w: colW[ci] - 0.16, h: rowH - 0.06,
        fontSize: isHeader ? 11 : 10, bold: isHeader,
        color: isHeader ? C.white : ci === 0 ? C.navy : C.mgray,
        fontFace: "Calibri", valign: "middle"
      });
    });
  });
}

// ══════════════════════════════════════════════════════════════════════════════
// SECTION DIVIDER — MANAGEMENT
// ══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  sectionDivider(s, "06", "Non-operative Management", "शस्त्रक्रियारहित उपचार", C.green);
}

// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 9 — NON-OPERATIVE MANAGEMENT
// ══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  addLightBg(s);
  slideTitle(s, "Non-operative Management", "शस्त्रक्रियारहित उपचार — ३-६ महिने प्रयत्न करावेत");

  infoBox(s, 0.4, 1.15, 4.0, 2.1,
    "Mechanical  |  यांत्रिक उपाय",
    "• Heel lift orthotics (टाच उशी)\n• Open-back shoes (मागे उघड्या चपला)\n• Silicone heel pad / doughnut pad\n• Activity modification\n• 3D walking boot (acute flares)",
    C.teal
  );

  infoBox(s, 4.65, 1.15, 4.0, 2.1,
    "Pharmacological  |  औषधोपचार",
    "• NSAIDs — oral or topical\n  (दाहविरोधी औषधे)\n• Short course only\n• Topical diclofenac gel useful",
    C.orange
  );

  infoBox(s, 9.3, 1.15, 3.6, 2.1,
    "Immobilisation  |  स्थिरीकरण",
    "• Walking boot for acute\n  inflammation\n• Short-leg cast for\n  recalcitrant cases\n• Night splint for morning pain",
    C.navy
  );

  infoBox(s, 0.4, 3.4, 4.0, 2.2,
    "Physical Therapy  |  भौतिक चिकित्सा",
    "• Eccentric heel drops\n  (एकाग्र टाच खाली करणे)\n• Heavy slow resistance (HSR)\n• Gastrosoleus stretching\n• Dry needling\n• Astym therapy",
    C.green
  );

  infoBox(s, 4.65, 3.4, 4.0, 2.2,
    "ESWT  |  शॉक वेव्ह थेरपी",
    "• Low-energy extracorporeal\n  shock wave therapy\n• For chronic cases (>6 weeks)\n• Good evidence for insertional\n  tendinopathy + bursitis\n  (जुनाट बर्सायटिससाठी उपयुक्त)",
    C.accent
  );

  // Red box — avoid steroid
  s.addShape(pres.shapes.RECTANGLE, {
    x: 9.3, y: 3.4, w: 3.6, h: 2.2,
    fill: { color: "FFF0F0" }, line: { color: C.red, width: 2 }
  });
  s.addShape(pres.shapes.RECTANGLE, {
    x: 9.3, y: 3.4, w: 3.6, h: 0.38, fill: { color: C.red }, line: { type: "none" }
  });
  s.addText("⚠  AVOID  |  टाळावे", {
    x: 9.4, y: 3.44, w: 3.4, h: 0.3,
    fontSize: 12, bold: true, color: C.white, fontFace: "Calibri", margin: 0
  });
  s.addText("Corticosteroid injection\nnear Achilles tendon!\n(कॉर्टिकोस्टेरॉइड इंजेक्शन\nअकिलीस कंडराजवळ देऊ नये)\n→ Risk of tendon RUPTURE\n→ Repeated injections = danger!\n\nPRP: Inconclusive evidence\n(PRP: अपुरा पुरावा)", {
    x: 9.4, y: 3.84, w: 3.4, h: 1.7,
    fontSize: 10.5, color: C.red, fontFace: "Calibri", bold: true
  });

  // Duration note
  s.addShape(pres.shapes.RECTANGLE, {
    x: 0.4, y: 5.75, w: 12.5, h: 0.65,
    fill: { color: C.teal }, line: { type: "none" }
  });
  s.addText("⏱  Try conservative treatment for MINIMUM 3-6 months before considering surgery  |  शस्त्रक्रियेपूर्वी किमान ३-६ महिने पुराणमतवादी उपचार करावेत", {
    x: 0.55, y: 5.82, w: 12.2, h: 0.5,
    fontSize: 12.5, bold: true, color: C.white, fontFace: "Calibri", align: "center"
  });
}

// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 10 — PHYSICAL THERAPY PROTOCOL (DETAILED)
// ══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  addLightBg(s);
  slideTitle(s, "Physical Therapy Protocol — 3 Phases", "भौतिक चिकित्सा — ३ टप्पे");

  const phases = [
    {
      title: "Phase 1 — Acute (Weeks 1-4)",
      marathi: "टप्पा १ — तीव्र अवस्था (आठवडे १-४)",
      color: C.red,
      content: "• Rest + activity modification\n• Ice 15-20 min, 3-4x daily (बर्फ शेक)\n• NSAIDs / topical anti-inflammatories\n• Heel lift in shoe (टाच उशी)\n• Night splint if morning pain\n• Walking boot for severe flares\n  (तीव्र वेदनांसाठी वॉकिंग बूट)",
    },
    {
      title: "Phase 2 — Subacute / Loading (Weeks 4-12)",
      marathi: "टप्पा २ — भार टाकण्याचा टप्पा (आठवडे ४-१२)",
      color: C.orange,
      content: "• Eccentric heel drops (एकाग्र टाच व्यायाम):\n  Stand on step edge, rise bilateral,\n  lower on AFFECTED leg slowly\n  3 sets × 15 reps, twice daily\n  Straight knee (gastrocnemius)\n  Bent knee (soleus)\n• Heavy Slow Resistance (HSR) training\n• Gastrosoleus stretch\n• Astym / dry needling\n• ESWT from week 6+ if needed",
    },
    {
      title: "Phase 3 — Return to Sport (Week 12+)",
      marathi: "टप्पा ३ — खेळात परतणे (आठवडा १२+)",
      color: C.green,
      content: "• Progressive plyometric loading\n  (हळूहळू उडी-प्रकारचे व्यायाम)\n• Sport-specific drills\n• Footwear optimisation\n  (योग्य बूट निवड)\n• Continue ESWT if needed\n• Gradually increase training load",
    },
  ];

  phases.forEach((ph, i) => {
    const x = 0.4 + i * 4.3;
    s.addShape(pres.shapes.RECTANGLE, {
      x, y: 1.15, w: 4.1, h: 5.9,
      fill: { color: C.white },
      line: { color: ph.color, width: 2 },
      shadow: { type: "outer", color: "000000", blur: 5, offset: 2, angle: 135, opacity: 0.1 }
    });
    s.addShape(pres.shapes.RECTANGLE, {
      x, y: 1.15, w: 4.1, h: 0.9,
      fill: { color: ph.color }, line: { type: "none" }
    });
    s.addText(ph.title, {
      x: x + 0.1, y: 1.18, w: 3.9, h: 0.48,
      fontSize: 12, bold: true, color: C.white, fontFace: "Calibri", margin: 0
    });
    s.addText(ph.marathi, {
      x: x + 0.1, y: 1.65, w: 3.9, h: 0.35,
      fontSize: 10, italic: true, color: C.white, fontFace: "Calibri", margin: 0
    });
    s.addText(ph.content, {
      x: x + 0.15, y: 2.15, w: 3.8, h: 4.8,
      fontSize: 11, color: C.navy, fontFace: "Calibri", valign: "top"
    });
  });
}

// ══════════════════════════════════════════════════════════════════════════════
// SECTION DIVIDER — OPERATIVE
// ══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  sectionDivider(s, "07", "Operative Management", "शस्त्रक्रिया उपचार", C.navy);
}

// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 11 — OPERATIVE OPTIONS (with intraop image)
// ══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  addSplitBg(s, C.navy, C.offwht, 5.5);
  darkSlideTitle(s, "Operative Management", "शस्त्रक्रिया उपचार — अपयशी पुराणमतवादी उपचारानंतर");

  s.addText([
    { text: "Indications  |  संकेत:\n", options: { bold: true, color: C.gold, fontSize: 13, breakLine: true } },
    { text: "• Failure of 3-6 months conservative care\n", options: { color: C.white, fontSize: 11 } },
    { text: "• Intractable posterior heel pain\n\n", options: { color: C.white, fontSize: 11 } },
    { text: "MRI before surgery: Quantify tendinosis\n", options: { bold: true, color: C.gold, fontSize: 12, breakLine: true } },
    { text: "• <50% tendinosis → Endoscopic / Zadek\n", options: { color: C.white, fontSize: 11 } },
    { text: "• >50% tendinosis → Debridement + FHL transfer\n\n", options: { color: C.white, fontSize: 11 } },
    { text: "Procedures  |  प्रक्रिया:\n", options: { bold: true, color: C.gold, fontSize: 13, breakLine: true } },
    { text: "1. Endoscopic Calcaneoplasty\n", options: { bold: true, color: C.accent, fontSize: 12, breakLine: true } },
    { text: "   Preferred — 80-100% good/excellent results\n   (दुर्बीण शस्त्रक्रिया — प्रथम पसंती)\n\n", options: { color: C.white, fontSize: 11 } },
    { text: "2. Zadek Osteotomy (Dorsal Closing Wedge)\n", options: { bold: true, color: C.accent, fontSize: 12, breakLine: true } },
    { text: "   <50% tendinosis; reduces calcaneal pitch\n\n", options: { color: C.white, fontSize: 11 } },
    { text: "3. Open Debridement + Exostectomy\n", options: { bold: true, color: C.gold, fontSize: 12, breakLine: true } },
    { text: "   For >50% tendinosis cases\n\n", options: { color: C.white, fontSize: 11 } },
    { text: "4. FHL Tendon Transfer (Augmentation)\n", options: { bold: true, color: C.gold, fontSize: 12, breakLine: true } },
    { text: "   If >50% Achilles footprint debrided\n", options: { color: C.white, fontSize: 11 } },
  ], { x: 0.4, y: 1.15, w: 4.8, h: 6.1, fontFace: "Calibri", valign: "top" });

  // Right — intraop image
  if (imgIntraop) {
    s.addImage({ data: imgIntraop, x: 5.8, y: 1.0, w: 5.0, h: 4.0 });
  }
  s.addText("Pre- and intraoperative radiographs — Haglund deformity excision\nहॅग्लंड विकृतीची शस्त्रक्रिया — पूर्व व दरम्यान क्ष-किरण\nSource: Miller's Review of Orthopaedics 9th Ed", {
    x: 5.8, y: 5.02, w: 5.0, h: 0.55,
    fontSize: 8.5, italic: true, color: C.mgray, fontFace: "Calibri", align: "center"
  });

  infoBox(s, 5.8, 5.65, 7.1, 1.65,
    "Gastrocnemius Recession  |  गॅस्ट्रोकनेमियस लांबवणे",
    "For cases with significant gastrosoleus contracture. Endoscopic > Open (fewer wound complications). Phisitkul prospective study: 320 patients — improved dorsiflexion + pain scores at 1 yr. Associated with plantarflexion weakness at 18 months.",
    C.mgray
  );
}

// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 12 — ENDOSCOPIC vs OPEN (Evidence Table)
// ══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  addLightBg(s);
  slideTitle(s, "Endoscopic vs Open Surgery — Evidence", "दुर्बीण वि. उघडी शस्त्रक्रिया — पुरावा");

  // Systematic review citation
  s.addShape(pres.shapes.RECTANGLE, {
    x: 0.4, y: 1.1, w: 12.5, h: 0.55,
    fill: { color: C.teal }, line: { type: "none" }
  });
  s.addText("Systematic Review: Alessio-Mazzola et al. (KSSTA 2021) — 1,260 ankles, 1,147 patients  |  PMID: 33216187", {
    x: 0.55, y: 1.15, w: 12.2, h: 0.42,
    fontSize: 11, bold: true, color: C.white, fontFace: "Calibri", align: "center"
  });

  const cols = ["Outcome", "Open Surgery", "Endoscopic Surgery", "p-value"];
  const data = [
    ["AOFAS Score", "87.1 ± 5.9", "90.7 ± 4.2", "< 0.001"],
    ["Complication Rate", "15.5%", "4.1%", "< 0.001"],
    ["Failure Rate", "6.0%", "1.2%", "< 0.001"],
    ["Return to Daily Activities", "17.2 weeks", "6.3 weeks", "< 0.001"],
    ["Return to Sport", "20.7 weeks", "11.9 weeks", "< 0.001"],
  ];

  const cw = [3.8, 2.8, 3.2, 2.5];
  const cx = [0.4, 4.25, 7.1, 10.35];
  const rh = 0.62;

  [...[cols], ...data].forEach((row, ri) => {
    row.forEach((cell, ci) => {
      const isHeader = ri === 0;
      const isBetter = !isHeader && ci === 2;
      s.addShape(pres.shapes.RECTANGLE, {
        x: cx[ci], y: 1.75 + ri * rh, w: cw[ci], h: rh,
        fill: { color: isHeader ? C.navy : isBetter ? "E8F9F0" : ri % 2 === 0 ? C.white : "F2F6FA" },
        line: { color: C.lgray, width: 0.5 }
      });
      s.addText(cell, {
        x: cx[ci] + 0.1, y: 1.78 + ri * rh, w: cw[ci] - 0.2, h: rh - 0.08,
        fontSize: isHeader ? 12 : 12.5, bold: isHeader || isBetter,
        color: isHeader ? C.white : isBetter ? C.green : ci === 3 ? C.red : C.navy,
        fontFace: "Calibri", align: "center", valign: "middle"
      });
    });
  });

  // Advantages list
  infoBox(s, 0.4, 5.42, 5.8, 1.83,
    "Advantages of Endoscopic Approach  |  दुर्बीण शस्त्रक्रियेचे फायदे",
    "• 4× lower complication rate\n• 5× lower failure rate\n• Return to sport almost HALF the time\n• Smaller incisions, better cosmesis\n• Lower sural nerve injury risk\n(कमी गुंतागुंत, जलद पुनर्प्राप्ती, कमी चट्टा)",
    C.green
  );

  infoBox(s, 6.55, 5.42, 6.35, 1.83,
    "Zadek Osteotomy Evidence  |  झाडेक ऑस्टिओटॉमी",
    "Poutoglidou et al. Systematic Review + Meta-analysis (Foot Ankle Surg 2023) — PMID: 37088671\nGood outcomes at 2 years. Best for <50% intrasubstance tendinosis on MRI. Minimally invasive approach preferred: fewer wound complications + lower sural nerve injury.\n(५०% पेक्षा कमी टेंडिनोसिससाठी उत्तम — जखमेचे कमी प्रश्न)",
    C.teal
  );
}

// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 13 — SPECIAL POPULATIONS
// ══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  addLightBg(s);
  slideTitle(s, "Special Populations & Clinical Pearls", "विशेष रुग्णगट व महत्त्वाचे मुद्दे");

  infoBox(s, 0.4, 1.15, 6.1, 1.95,
    "Athletes  |  खेळाडू",
    "High return-to-sport demand → endoscopic approach preferred.\nEccentric training (Alfredson protocol) for 12 weeks before surgery.\n'Pump bump' — Haglund classically described in women's high-heeled shoes.\n(खेळाडूंसाठी दुर्बीण शस्त्रक्रिया उत्तम — जलद परत येणे)",
    C.teal
  );

  infoBox(s, 6.75, 1.15, 6.15, 1.95,
    "Spondyloarthropathy / RA  |  स्पॉन्डिलोआर्थ्रोपॅथी / RA",
    "Systemic DMARDs / biologics (anti-TNF, anti-IL17) required.\nBilateral presentation → always suspect systemic cause.\nCorticosteroid injection more acceptable in inflammatory arthritis\n(synovitis not tendinosis).\n(द्विपक्षीय असेल तर प्रणालीगत कारण शोधा)",
    C.orange
  );

  infoBox(s, 0.4, 3.25, 6.1, 1.95,
    "Children — Sever's Disease  |  मुलांमध्ये — सेव्हर आजार",
    "True retrocalcaneal bursitis rare in children.\nSever's disease (calcaneal apophysitis): ages 7-10, activity-related posterior heel.\nTreatment: Rest, ice, heel pads — self-limiting.\nX-rays NOT needed unless other diagnosis suspected.\n(बहुतांश वेळी हा आजार स्वतःहून बरा होतो)",
    C.green
  );

  infoBox(s, 6.75, 3.25, 6.15, 1.95,
    "Gout / Crystal Arthropathy  |  गाउट",
    "Urate crystals may deposit in retrocalcaneal bursa.\nAcute attacks → colchicine / NSAIDs / corticosteroid (in bursa, not tendon).\nSerum uric acid, joint aspirate for crystals.\nRheumatoid arthritis can also affect the bursa.\n(युरेट क्रिस्टल बर्सात साचतात — तीव्र वेदना)",
    C.red
  );

  // Fluoroquinolone big warning
  s.addShape(pres.shapes.RECTANGLE, {
    x: 0.4, y: 5.35, w: 12.5, h: 1.9,
    fill: { color: "FFF3CD" }, line: { color: C.orange, width: 2 }
  });
  s.addShape(pres.shapes.RECTANGLE, {
    x: 0.4, y: 5.35, w: 12.5, h: 0.42, fill: { color: C.orange }, line: { type: "none" }
  });
  s.addText("⚠  Fluoroquinolone-Induced Tendinopathy  |  फ्लुरोक्विनोलोन-प्रेरित टेंडिनोपॅथी", {
    x: 0.55, y: 5.38, w: 12.2, h: 0.35,
    fontSize: 12, bold: true, color: C.white, fontFace: "Calibri", align: "center", margin: 0
  });
  s.addText(
    "Ciprofloxacin / Levofloxacin → Achilles tendinopathy ± rupture  |  Can occur during or WEEKS AFTER drug use\n" +
    "STOP fluoroquinolone IMMEDIATELY on recognition  |  Inform patient before prescribing!\n" +
    "फ्लुरोक्विनोलोन वापरताना किंवा वापरल्यानंतर काही आठवड्यांनी कंडरा फुटण्याचा धोका — औषध त्वरित बंद करावे",
    {
      x: 0.55, y: 5.82, w: 12.2, h: 1.3,
      fontSize: 11.5, color: C.navy, fontFace: "Calibri", align: "center"
    }
  );
}

// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 14 — MANAGEMENT ALGORITHM
// ══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  addLightBg(s);
  slideTitle(s, "Management Algorithm", "उपचाराचा मार्गदर्शक आराखडा");

  // Flow boxes
  const boxes = [
    { x: 4.3, y: 1.1, w: 4.7, h: 0.6, text: "Posterior Heel Pain\nमागील टाचदुखी", col: C.navy },
    { x: 4.3, y: 1.9, w: 4.7, h: 0.6, text: "Clinical Exam + Standing Lateral X-ray\nशारीरिक तपासणी + क्ष-किरण", col: C.teal },
    { x: 4.3, y: 2.7, w: 4.7, h: 0.6, text: "Systemic Cause? (SpA/RA/Gout)\nप्रणालीगत कारण?", col: C.orange },
  ];
  boxes.forEach(b => {
    s.addShape(pres.shapes.RECTANGLE, {
      x: b.x, y: b.y, w: b.w, h: b.h,
      fill: { color: b.col }, line: { type: "none" },
      shadow: { type: "outer", color: "000000", blur: 4, offset: 2, angle: 135, opacity: 0.15 }
    });
    s.addText(b.text, {
      x: b.x + 0.1, y: b.y, w: b.w - 0.2, h: b.h,
      fontSize: 11.5, bold: true, color: C.white, fontFace: "Calibri",
      align: "center", valign: "middle"
    });
  });

  // Arrows between boxes
  [1.7, 2.5, 3.3].forEach(y => {
    s.addShape(pres.shapes.RECTANGLE, { x: 6.5, y, w: 0.3, h: 0.2, fill: { color: C.gold }, line: { type: "none" } });
  });

  // YES / NO branches from systemic
  s.addText("YES → DMARDs + Biologics\nहो → रोगप्रतिकारक औषधे", {
    x: 0.4, y: 3.38, w: 3.7, h: 0.6,
    fontSize: 11, color: C.white, fontFace: "Calibri", align: "center", valign: "middle",
    fill: { color: C.red }
  });
  s.addShape(pres.shapes.RECTANGLE, {
    x: 0.4, y: 3.38, w: 3.7, h: 0.6, fill: { color: C.red }, line: { type: "none" }
  });
  s.addText("YES → DMARDs + Biologics\nहो → रोगप्रतिकारक औषधे", {
    x: 0.5, y: 3.38, w: 3.5, h: 0.6,
    fontSize: 11, color: C.white, fontFace: "Calibri", align: "center", valign: "middle"
  });

  // Conservative box
  s.addShape(pres.shapes.RECTANGLE, {
    x: 4.3, y: 3.5, w: 4.7, h: 0.65, fill: { color: C.green }, line: { type: "none" }
  });
  s.addText("Conservative (3-6 months)\nपुराणमतवादी उपचार ३-६ महिने", {
    x: 4.4, y: 3.5, w: 4.5, h: 0.65,
    fontSize: 11.5, bold: true, color: C.white, fontFace: "Calibri", align: "center", valign: "middle"
  });
  s.addText("Heel lift • NSAIDs • Eccentric exercise • Night splint • ESWT  |  टाच उशी • दाहविरोधी • व्यायाम • रात्री स्प्लिंट", {
    x: 4.4, y: 4.22, w: 4.5, h: 0.35,
    fontSize: 10, italic: true, color: C.teal, fontFace: "Calibri", align: "center"
  });

  // Failed conservative
  s.addShape(pres.shapes.RECTANGLE, {
    x: 4.3, y: 4.65, w: 4.7, h: 0.55, fill: { color: C.mgray }, line: { type: "none" }
  });
  s.addText("Failed Conservative? → MRI\nअपयश? → MRI करा", {
    x: 4.4, y: 4.65, w: 4.5, h: 0.55,
    fontSize: 11.5, bold: true, color: C.white, fontFace: "Calibri", align: "center", valign: "middle"
  });

  // Two surgical branches
  s.addShape(pres.shapes.RECTANGLE, {
    x: 0.4, y: 5.4, w: 5.8, h: 1.6, fill: { color: C.teal }, line: { type: "none" }
  });
  s.addText("<50% Tendinosis\n५०%पेक्षा कमी टेंडिनोसिस\n\nEndoscopic Calcaneoplasty\nor Zadek Osteotomy\n(दुर्बीण शस्त्रक्रिया / झाडेक ऑस्टिओटॉमी)", {
    x: 0.5, y: 5.42, w: 5.6, h: 1.55,
    fontSize: 12, bold: true, color: C.white, fontFace: "Calibri", align: "center", valign: "middle"
  });

  s.addShape(pres.shapes.RECTANGLE, {
    x: 7.1, y: 5.4, w: 5.8, h: 1.6, fill: { color: C.red }, line: { type: "none" }
  });
  s.addText(">50% Tendinosis\n५०%पेक्षा जास्त टेंडिनोसिस\n\nDebridement + Exostectomy\n+ FHL Tendon Transfer\n(कंडरा दुरुस्ती + FHL बदली)", {
    x: 7.2, y: 5.42, w: 5.6, h: 1.55,
    fontSize: 12, bold: true, color: C.white, fontFace: "Calibri", align: "center", valign: "middle"
  });
}

// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 15 — QUICK REFERENCE SUMMARY
// ══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  addLightBg(s);
  slideTitle(s, "Quick Reference Summary", "जलद संदर्भ सारांश");

  const rows = [
    ["Topic", "Key Fact", "Marathi Note"],
    ["Bursa Location", "Deep to Achilles, between tendon & posterosuperior calcaneus", "अकिलीस कंडराच्या खाली"],
    ["Haglund Deformity", "Posterosuperior calcaneal exostosis (anterior to tendon)", "पोस्टेरोसुपेरियर हाडाची वाढ"],
    ["Key Exam Sign", "Mediolateral squeeze → fluid fluctuation", "मध्य-पार्श्व पिळणे चाचणी"],
    ["First Imaging", "Standing lateral heel X-ray", "उभे राहून पार्श्व टाच क्ष-किरण"],
    ["AVOID", "Corticosteroid injection near Achilles", "अकिलीसजवळ इंजेक्शन टाळा"],
    ["ESWT", "Chronic cases >6 weeks", "जुनाट रुग्णांसाठी शॉक वेव्ह"],
    ["Surgery threshold", "After 3-6 months failed conservative", "३-६ महिने अपयशानंतर"],
    ["Preferred Surgery", "Endoscopic calcaneoplasty (90.7 AOFAS, 4.1% complications)", "दुर्बीण शस्त्रक्रिया — प्रथम पसंती"],
    [">50% Tendinosis", "Debridement + FHL transfer", "FHL बदली आवश्यक"],
    ["Zadek Osteotomy", "<50% tendinosis, high calcaneal pitch", "कमी टेंडिनोसिससाठी"],
    ["Fluoroquinolones", "Stop immediately if tendinopathy develops", "फ्लुरोक्विनोलोन त्वरित बंद करा"],
    ["Systemic Causes", "SpA, RA, Gout, CPPD, Ochronosis", "प्रणालीगत कारणे"],
  ];

  const cw = [2.4, 5.5, 4.4];
  const cx = [0.4, 2.85, 8.4];
  const rh = 0.49;
  rows.forEach((row, ri) => {
    row.forEach((cell, ci) => {
      const isHeader = ri === 0;
      s.addShape(pres.shapes.RECTANGLE, {
        x: cx[ci], y: 1.1 + ri * rh, w: cw[ci], h: rh,
        fill: { color: isHeader ? C.navy : ri % 2 === 0 ? C.white : "EDF3F8" },
        line: { color: C.lgray, width: 0.5 }
      });
      s.addText(cell, {
        x: cx[ci] + 0.07, y: 1.13 + ri * rh, w: cw[ci] - 0.14, h: rh - 0.08,
        fontSize: isHeader ? 11 : 10.5, bold: isHeader || ci === 0,
        color: isHeader ? C.white : ci === 0 ? C.navy : C.mgray,
        fontFace: "Calibri", valign: "middle"
      });
    });
  });
}

// ══════════════════════════════════════════════════════════════════════════════
// SLIDE 16 — REFERENCES & THANK YOU
// ══════════════════════════════════════════════════════════════════════════════
{
  const s = pres.addSlide();
  addDarkBg(s, C.navy);
  s.addShape(pres.shapes.RECTANGLE, { x: 0, y: 0, w: 0.55, h: 7.5, fill: { color: C.gold }, line: { type: "none" } });
  s.addShape(pres.shapes.RECTANGLE, { x: 0, y: 5.6, w: 13.3, h: 1.9, fill: { color: C.teal }, line: { type: "none" } });

  s.addText("References & Sources", {
    x: 0.75, y: 0.25, w: 12.1, h: 0.55,
    fontSize: 26, bold: true, color: C.white, fontFace: "Calibri"
  });
  s.addText("संदर्भ व स्रोत", {
    x: 0.75, y: 0.78, w: 12.1, h: 0.38,
    fontSize: 15, italic: true, color: C.gold, fontFace: "Calibri"
  });

  const refs = [
    "1. Campbell's Operative Orthopaedics 15th Ed 2026 — Chapters 55 (Tendoscopy) & 88 (Insertional Achilles Tendinopathy)",
    "2. Miller's Review of Orthopaedics 9th Edition — Chapter 6 (Foot & Ankle)",
    "3. Goldman-Cecil Medicine (International Ed) — Chapter 40 (Disorders of the Ankle and Foot)",
    "4. Grainger & Allison's Diagnostic Radiology — Musculoskeletal Imaging (Tendons, p.1000)",
    "5. Roberts & Hedges' Clinical Procedures in Emergency Medicine — Chapter 51 (Heel Pain)",
    "6. Alessio-Mazzola M et al. Endoscopic calcaneoplasty for Haglund's deformity. KSSTA 2021 — PMID: 33216187",
    "7. Yuen WLP et al. Surgical Treatment of Haglund's Deformity: Systematic Review. Cureus 2022 — PMID: 36060327",
    "8. Poutoglidou F et al. Zadek calcaneal osteotomy in insertional Achilles tendinopathy: Meta-analysis. Foot Ankle Surg 2023 — PMID: 37088671",
  ];

  s.addText(refs.join("\n\n"), {
    x: 0.75, y: 1.3, w: 12.2, h: 4.1,
    fontSize: 10.5, color: C.lgray, fontFace: "Calibri", valign: "top"
  });

  s.addText("रेट्रोकॅल्केनियल बर्सायटिस — शरीररचनेपासून उपचारापर्यंत", {
    x: 0.75, y: 5.72, w: 12.1, h: 0.45,
    fontSize: 16, bold: true, color: C.white, fontFace: "Calibri", align: "center"
  });
  s.addText("Retrocalcaneal Bursitis — From Anatomy to Management  |  Orris Medical Reference 2026", {
    x: 0.75, y: 6.18, w: 12.1, h: 0.35,
    fontSize: 11, color: C.white, fontFace: "Calibri", align: "center"
  });
}

// ══════════════════════════════════════════════════════════════════════════════
// WRITE FILE
// ══════════════════════════════════════════════════════════════════════════════
pres.writeFile({ fileName: "/home/daytona/workspace/retrocalcaneal-ppt/Retrocalcaneal_Bursitis_Complete.pptx" })
  .then(() => console.log("SUCCESS: PPTX written."))
  .catch(e => { console.error("ERROR:", e); process.exit(1); });

Successfully replaced 1 instance(s) of the string in '/home/daytona/workspace/retrocalcaneal-ppt/make_ppt.js'