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Hall S, Schipper O, Kaplan JRM, Johnson AH, Gonzalez TA, Vulcano E. Outcomes After Percutaneous Zadek Osteotomy for Insertional Achilles Tendinopathy. Foot Ankle Int 2024:10711007241252803. [PMID: 39219246 DOI: 10.1177/10711007241252803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/04/2024]
Abstract
BACKGROUND Surgical treatment of insertional Achilles tendinopathy (IAT) historically consists of Achilles tendon debridement with reattachment and excision of the posterosuperior calcaneal prominence with or without a gastrocnemius recession. Zadek osteotomy (ZO) is an alternative to an open midline splitting approach. The purpose of this study was to analyze patient-reported outcomes and complications after percutaneously performed ZO with minimum 2 years' follow-up. METHODS One hundred eight cases treated with percutaneous ZO with a minimum 2-year follow-up were retrospectively reviewed. Postoperative complications and patient satisfaction were evaluated. Foot Function Index (FFI) and visual analog scale (VAS) scores were recorded at preoperative and follow-up appointments to measure patients' functional outcomes and pain, respectively. RESULTS Mean follow-up was 41.2 months (range, 24-65). Mean age was 51.8 years (range, 28-81). The mean FFI score improved from 56.1 (range, 47-88) to 11.0 (range, 7-59) postoperatively (P < .001). The mean VAS score improved from 7.7 (range, 5-10) to 0.4 (range, 0-7) postoperatively (P < .001). The overall complication rate was 3.8% (n = 4). Of 104 cases, 98.1% of patients said they were satisfied with their procedure (n = 102) when asked if they were satisfied with their ZO and recovery. CONCLUSION We found the percutaneous ZO to be a safe and effective intervention for treatment of IAT. At a minimum of 2-year follow-up, this intervention is associated with minimal complications, improved function, reduced pain, and a high rate of patient satisfaction.Level of Evidence: Level IV, retrospective cohort study.
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Affiliation(s)
- SarahRose Hall
- University of South Carolina, School of Medicine, Columbia, SC, USA
| | | | | | | | - Tyler A Gonzalez
- University of South Carolina, School of Medicine, Columbia, SC, USA
- Prisma Health Orthopedics, Lexington, SC, USA
| | - Ettore Vulcano
- Columbia University Division of Orthopedics at Mount Sinai Medical Center, Miami Beach, FL, USA
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Drakos MC. MIS Osteotomies: Expanding the Scope of Treatment. Foot Ankle Int 2024:10711007241268177. [PMID: 39219242 DOI: 10.1177/10711007241268177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/04/2024]
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Kaplan JRM, Hall S, Kumar P, DiTommaso RM, Giles SS, Gonzalez TA, Haupt E. Dorsal calcaneal wedge removal in zadek osteotomy: A cadaveric study. Foot Ankle Surg 2024; 30:516-519. [PMID: 38692981 DOI: 10.1016/j.fas.2024.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 03/08/2024] [Accepted: 04/06/2024] [Indexed: 05/03/2024]
Abstract
BACKGROUND Insertional Achilles tendinopathy (IAT) is a common pathology with multiple surgical interventions available for treatment. The Zadek, dorsal closing wedge calcaneal osteotomy (ZO) has been demonstrated to be effective treatment of IAT. There have been various recommendations in the literature as to what measurement of wedge removal should be considered ideal to produce greatest postoperative range of motion (ROM), thus postoperative biomechanical potential. Accordingly, the purpose of this cadaveric study was to assess the range of motion achieved after various measurements of wedge removal by ZO. METHODS The ZO was performed on six cadaveric specimens. A 7.5 mm and 15 mm wedge osteotomy was marked and sequentially completed on each specimen. Lateral fluoroscopic imaging was utilized to take preoperative and postoperative ROM measurements for each osteotomy. Dorsiflexion (DF) and plantarflexion (PF) ROM arcs were measured for each wedge size and compared by t-test. Effect sizes were calculated by Cohen's d analysis. RESULTS Maximal DF was 110.87 ± 12.97 deg in the pre-osteotomy state. Removal of a 7.5 mm wedge improved DF by 8 deg to a mean 102.93 ± 13.81 deg (p = 0.08). Removal of a 15 mm wedge improved DF by 16 deg to a mean 95.96 ± 11.41 deg (p = 0.003). Cohen's d and effect size calculation demonstrated a 7.5 mm wedge to have a small effect on DF, while a 15 mm wedge had a medium effect (0.29, 0.52 respectively). Maximal PF did not change significantly amongst the pre-osteotomy, 7.5 mm wedge, or 15 mm wedge positions. ICC was 0.96. CONCLUSION Based on the results presented in this study, removal of a 15 mm wedge with ZO yields significant and greater improvement in ROM than a 7.5 mm wedge. We hope the current study will better inform preoperative planning for ZO. STUDY TYPE Prospective Cadaver Study. LEVEL OF EVIDENCE V.
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Affiliation(s)
| | - SarahRose Hall
- University of South Carolina, School of Medicine, 6311 Garners Ferry Rd., Columbia, SC 29209, USA.
| | - Padam Kumar
- Prisma Health Orthopedics - Lexington, 104 Saluda Pointe Drive, Lexington, SC 29072, USA.
| | - Rita M DiTommaso
- Mayo Clinic Florida,1515 Sw Archer Rd, Gainesville, FL 32608, USA.
| | | | - Tyler A Gonzalez
- University of South Carolina, School of Medicine, 6311 Garners Ferry Rd., Columbia, SC 29209, USA; Prisma Health Orthopedics - Lexington, 104 Saluda Pointe Drive, Lexington, SC 29072, USA.
| | - Edward Haupt
- Mayo Clinic Florida,1515 Sw Archer Rd, Gainesville, FL 32608, USA
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Friesenbichler B, Rutishauer T, Rippstein P, List R, Monn S, Mainzer J, Maffiuletti NA. Ankle Muscle Strength and Gait Function After Dorsal Closing Wedge Calcaneal Osteotomy for Haglund Exostosis-Related Heel Pain. Foot Ankle Int 2024; 45:701-710. [PMID: 38618683 DOI: 10.1177/10711007241241264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/16/2024]
Abstract
BACKGROUND Haglund exostosis-related heel pain may be surgically treated with dorsal closing wedge calcaneal osteotomy (DCWCO). Recent reports on this technique show good clinical and self-reported outcomes. However, uncertainty about functional consequences related to ankle muscle strength and gait function due to a shortened Achilles tendon lever arm exists. METHODS Fifteen patients (15 feet) with Haglund exostosis-related heel pain were surgically treated with DCWCO and evaluated before and 1 year after surgery. Isometric plantar flexion and dorsiflexion strength was quantified for both the involved and the uninvolved limb. Gait analysis was performed at a self-selected walking speed using a 3D motion capture system including force plates. Self-reported outcomes (Foot Function Index and Global Treatment Outcome) were also assessed. RESULTS Before surgery, as well as after surgery, plantar flexion strength of the involved limb was significantly lower compared to the uninvolved limb while dorsiflexion strength did not differ between limbs at both time points. Step length and time, ankle flexion angles, power generation, and propulsive impulses during gait did not differ between limbs both before and after surgery. Propulsive impulse and step length of the involved limb increased from pre- to postsurgery with an effect size of 1.04 and 0.48, respectively, revealing a general improvement in gait dynamics. Total Foot Function Index improved by 48% after surgery, and 80% of patients rated their surgery as "helped" or "helped a lot" (Global Treatment Outcome). CONCLUSION In this relatively small cohort, we found that patients treated for Haglund exostosis-related heel pain with DCWCO surgery had minor interlimb differences in gait kinematics and kinetics and generally improved gait dynamics and self-reported function at 1-year follow-up. LEVEL OF EVIDENCE Level II, observational prospective cohort study.
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Affiliation(s)
| | | | | | - Renate List
- Human Performance Lab, Schulthess Clinic, Zurich, Switzerland
| | - Samara Monn
- Human Performance Lab, Schulthess Clinic, Zurich, Switzerland
| | - Jens Mainzer
- Foot Surgery Team, Schulthess Clinic, Zurich, Switzerland
- In Motion, Zentrum für Orthopädie und Neurochirurgie, Wallisellen, Switzerland
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Hall S, Kaplan JRM, Schipper ON, Vulcano E, Johnson AH, Jackson JB, Aiyer AA, Gonzalez TA. Minimally Invasive Approaches to Haglund's Deformity and Insertional Achilles Tendinopathy: A Contemporary Review. Foot Ankle Int 2024; 45:664-675. [PMID: 38647216 PMCID: PMC11165941 DOI: 10.1177/10711007241237529] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/25/2024]
Affiliation(s)
- SarahRose Hall
- University of South Carolina, School of Medicine, Columbia, SC, USA
| | | | | | - Ettore Vulcano
- Department of Orthopaedic Surgery, Columbia University Mount Sinai Medical Center, Miami Beach, FL, USA
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Nunes GA, Mendes de Carvalho KA, Schmidt E, Kim KC, Valvecchi TF, Mansur NSB, Zambelli R, Cesar Netto CD. Biomechanical consequences of Zadek osteotomy in insertional achilles tendinopathy: A virtual surgical simulation study. Foot Ankle Surg 2024:S1268-7731(24)00116-4. [PMID: 38839460 DOI: 10.1016/j.fas.2024.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Revised: 05/07/2024] [Accepted: 05/26/2024] [Indexed: 06/07/2024]
Abstract
BACKGROUND The Zadek osteotomy modified by Taylor (ZO) is a surgical technique used to treat insertional Achilles tendinopathy (IAT) by reducing the heel's prominence and elevating the Achilles tendon insertion. This study aims to analyze the biomechanical consequences of IAT after ZO using a virtual surgical simulation with a specific software. METHODS A retrospective analysis of 20 wtbearing computed tomography (WBCT) scans of IAT patients was conducted. Using Disior's BonelogicTM software, 3D models were created from WBCT images. Virtual ZO was performed on these models, and various biomechanical parameters were measured before and after the virtual osteotomy. RESULTS The virtual ZO showed significant statistical differences in the average of the calcaneal length (p < 0.001), Fowler Philips angle (p < 0.001), calcaneal pitch (p < 0.001), and the sagittal talocalcaneal angle (p < 0.001). CONCLUSIONS The virtual ZO analysis suggests that this procedure can decrease the Fowler Philips angle, shorten the calcaneus, modifying specifically the sagittal alignment. LEVEL OF EVIDENCE IV; case series.
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Affiliation(s)
- Gustavo Araujo Nunes
- COTE Brasília Clinic, Foot and Ankle Unit, Brasília, DF, Brazil; MIFAS by GRECMIP: Minimally Invasive Foot and Ankle Society, Brazil.
| | - Kepler Alencar Mendes de Carvalho
- University of Iowa Hospitals and Clinics Department of Orthopedics and Rehabilitation, Iowa City, IA, USA; Department of Orthopaedics, Duke University Medical Center, Durham, NC, USA
| | - Eli Schmidt
- University of Iowa Hospitals and Clinics Department of Orthopedics and Rehabilitation, Iowa City, IA, USA
| | - Ki Chun Kim
- Department of Orthopaedic Surgery, Seoul Medical Center, Seoul, Republic of Korea
| | | | - Nacime Salomão Barbachan Mansur
- University of Iowa Hospitals and Clinics Department of Orthopedics and Rehabilitation, Iowa City, IA, USA; Department of Orthopedics and Rehabilitation, Paulista School of Medicine, Federal University of Sao Paulo, Brazil
| | - Roberto Zambelli
- Faculdade de Ciências Médicas de Minas Gerais, Belo Horizonte, MG, Brazil
| | - Cesar de Cesar Netto
- University of Iowa Hospitals and Clinics Department of Orthopedics and Rehabilitation, Iowa City, IA, USA; Department of Orthopaedics, Duke University Medical Center, Durham, NC, USA
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Flores DV, Goes PK, Damer A, Huang BK. The Heel Complex: Anatomy, Imaging, Pathologic Conditions, and Treatment. Radiographics 2024; 44:e230163. [PMID: 38512730 DOI: 10.1148/rg.230163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2024]
Abstract
The differential diagnosis for heel pain is broad but primarily involves abnormalities of the Achilles tendon, calcaneus, and plantar fascia. Achilles tendon disorders include tendinosis, tendinitis, and partial or complete tears. Tendinosis refers to tendon degeneration, while tendinitis is inflammation after acute overload. Untreated tendinosis can progress to partial or complete tears. Tendon disorders can be accompanied by paratenonitis or inflammation of the loose sheath enclosing the tendon. Initial management involves rehabilitation and image-guided procedures. Operative management is reserved for tendon tears and includes direct repair, tendon transfer, and graft reconstruction. The calcaneus is the most commonly fractured tarsal bone. The majority of fractures are intra-articular; extra-articular fractures, stress or insufficiency fractures, medial process avulsion, and neuropathic avulsion can also occur. Posterosuperior calcaneal exostosis or Haglund deformity, retrocalcaneal bursitis, and insertional Achilles tendinosis form the characteristic triad of Haglund syndrome. It is initially managed with orthotics and physiotherapy. Operative management aims to correct osseous or soft-tissue derangements. The plantar fascia is a strong fibrous tissue that invests the sole of the foot and contributes to midfoot stability. Inflammation or plantar fasciitis is the most common cause of heel pain and can be related to overuse or mechanical causes. Acute rupture is less common but can occur in preexisting plantar fasciitis. Conservative treatment includes footwear modification, calf stretches, and percutaneous procedures. The main operative treatment is plantar fasciotomy. Plantar fibromatosis is a benign fibroblastic proliferation within the fascia that can be locally aggressive and is prone to recurrence. ©RSNA, 2024 Test Your Knowledge questions for this article are available in the supplemental material.
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Affiliation(s)
- Dyan V Flores
- From the Department of Radiology, Radiation Oncology, and Medical Physics, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada (D.V.F., A.D.); Department of Medical Imaging, The Ottawa Hospital, 501 Smyth Road, Ottawa, ON, Canada K1H 8L6 (D.V.F.); Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (D.V.F.); Division of Musculoskeletal Radiology, Laboratorio Delboni Auriemo, DASA, São Paulo, Brazil (P.K.G.); and Division of Musculoskeletal Imaging and Intervention, Department of Radiology, University of California San Diego Medical Center, San Diego, Calif (B.K.H.)
| | - Paola Kuenzer Goes
- From the Department of Radiology, Radiation Oncology, and Medical Physics, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada (D.V.F., A.D.); Department of Medical Imaging, The Ottawa Hospital, 501 Smyth Road, Ottawa, ON, Canada K1H 8L6 (D.V.F.); Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (D.V.F.); Division of Musculoskeletal Radiology, Laboratorio Delboni Auriemo, DASA, São Paulo, Brazil (P.K.G.); and Division of Musculoskeletal Imaging and Intervention, Department of Radiology, University of California San Diego Medical Center, San Diego, Calif (B.K.H.)
| | - Alameen Damer
- From the Department of Radiology, Radiation Oncology, and Medical Physics, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada (D.V.F., A.D.); Department of Medical Imaging, The Ottawa Hospital, 501 Smyth Road, Ottawa, ON, Canada K1H 8L6 (D.V.F.); Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (D.V.F.); Division of Musculoskeletal Radiology, Laboratorio Delboni Auriemo, DASA, São Paulo, Brazil (P.K.G.); and Division of Musculoskeletal Imaging and Intervention, Department of Radiology, University of California San Diego Medical Center, San Diego, Calif (B.K.H.)
| | - Brady K Huang
- From the Department of Radiology, Radiation Oncology, and Medical Physics, Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada (D.V.F., A.D.); Department of Medical Imaging, The Ottawa Hospital, 501 Smyth Road, Ottawa, ON, Canada K1H 8L6 (D.V.F.); Ottawa Hospital Research Institute, Ottawa, Ontario, Canada (D.V.F.); Division of Musculoskeletal Radiology, Laboratorio Delboni Auriemo, DASA, São Paulo, Brazil (P.K.G.); and Division of Musculoskeletal Imaging and Intervention, Department of Radiology, University of California San Diego Medical Center, San Diego, Calif (B.K.H.)
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Bakaes Y, Hall S, Jackson JB, Johnson AH, Schipper ON, Vulcano E, Kaplan JRM, Gonzalez TA. Percutaneous vs Open Zadek Osteotomy for Treatment of Insertional Achilles Tendinopathy and Haglund's Deformity: A Systematic Review. FOOT & ANKLE ORTHOPAEDICS 2024; 9:24730114241241320. [PMID: 38617581 PMCID: PMC11015789 DOI: 10.1177/24730114241241320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/16/2024] Open
Abstract
Background Percutaneous Zadek osteotomy (ZO) has emerged as a surgical treatment of insertional Achilles tendinopathy (IAT) over the last decade. Existing literature is limited regarding the comparison of this approach with the more established, open ZO technique. This systematic review aims to evaluate and compare the current data on open vs percutaneous ZO approaches to help set evidence-based guidelines. Methods A systematic literature search was performed using the keywords (Zadek osteotomy) OR (Keck and Kelly osteotomy) OR (dorsal closing wedge calcaneal osteotomy) OR (Haglund Deformity) OR (Haglund Syndrome) OR (Insertional Achilles Tendinopathy) and MeSH terms Osteotomy, Calcaneus, Syndrome, Insertional, Achilles tendon, and Tendinopathy. Our search included the following databases: PubMed, Embase, and the Cochrane Library. The PRISMA protocol and the Cochrane Handbook guidelines were followed. All studies included were published from 2009 to 2024 and included the use of open or percutaneous approaches of ZO for the treatment of IAT with at least a 12-month follow-up. The MINORS score criteria were used to evaluate the strength and quality of studies. Results A total of 17 studies were reviewed, including 611 subjects and 625 ZO procedures. Of these procedures, 81 (11%) subjects had a percutaneous and 544 (89%) subjects had an open ZO. The mean follow-up time was 16.1 months for patients treated with percutaneous ZO and 36.1 months for patients treated with open ZO. Both open and percutaneous studies included in this review showed postoperative improvements in AOFAS, FFI, VISA-A, and VAS scores in patients with IAT. The reported complication rate was 5.8% among patients treated with percutaneous ZO and 10.2% among patients treated with open ZO. Conclusion Percutaneous ZO is an emerging approach with substantially fewer documented cases compared with the open ZO. Both percutaneous and open ZO appear to be relatively effective treatments for insertional Achilles tendinopathy with Haglund's deformity. The lower complication rates reported for percutaneous ZO is encouraging. Further investigation with more subjects undergoing percutaneous ZO is clearly needed.
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Affiliation(s)
- Yianni Bakaes
- School of Medicine, University of South Carolina, Columbia, SC, USA
| | - SarahRose Hall
- School of Medicine, University of South Carolina, Columbia, SC, USA
| | - J. Benjamin Jackson
- School of Medicine, University of South Carolina, Columbia, SC, USA
- Prisma Health Orthopedics, Lexington, SC, USA
| | | | | | - Ettore Vulcano
- Columbia University Division of Orthopedics at Mount Sinai Medical Center, Miami Beach, FL, USA
| | | | - Tyler A. Gonzalez
- School of Medicine, University of South Carolina, Columbia, SC, USA
- Prisma Health Orthopedics, Lexington, SC, USA
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Karaismailoglu B, Altun AS, Subasi O, Sharma S, Peiffer M, Ashkani-Esfahani S, DiGiovanni CW, Bejarano-Pineda L. Comparison between achilles tendon reinsertion and dorsal closing wedge calcaneal osteotomy for the treatment of insertional achilles tendinopathy: A meta-analysis. Foot Ankle Surg 2024; 30:92-98. [PMID: 37838530 DOI: 10.1016/j.fas.2023.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Revised: 09/04/2023] [Accepted: 09/28/2023] [Indexed: 10/16/2023]
Abstract
BACKGROUND The debridement and Achilles tendon reinsertion (DATR) have been the most common surgical approach for the treatment of Insertional Achilles Tendinopathy (IAT), while dorsal closing wedge calcaneal osteotomy (DCWCO) has recently gained popularity as an alternative surgical option. This study aimed to systematically review the published literature on both surgical techniques and compare their clinical outcomes and complication rates. METHODS A systematic review was performed according to the PRISMA guidelines using Medline, Embase, and Scopus databases. The inclusion criteria encompassed clinical studies reporting functional outcomes and complications, with a minimum of 10 patients and at least 12 months of follow-up. RESULTS Seven studies (n = 169) were included for the analysis of DATR, and eight studies (n = 227) were included for the analysis of open DCWCO. Both groups showed a similar improvement in AOFAS score. The overall complication rates were 16.6% in the DATR group and 9.2% in the DCWCO group, but the difference was not statistically significant. However, there was a significantly higher incidence of wound complications in the DATR group (10.1%, 95% C.I.: 4.7-15.6) compared to the DCWCO group (2.5%, 95% C.I.: 0.6-4.4) as the confidence intervals did not overlap. CONCLUSIONS Clinical outcomes and overall complication rates of both techniques were comparable, although DCWCO had a lower incidence of wound complications. Further research should be focused on prospective studies comparing the two techniques to corroborate the current findings. LEVEL OF EVIDENCE Level IV; meta-analysis.
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Affiliation(s)
- Bedri Karaismailoglu
- Foot & Ankle Research and Innovation Lab (FARIL), Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Department of Orthopaedics and Traumatology, Istanbul University-Cerrahpasa, Istanbul, Turkey; CAST (Cerrahpasa Research, Simulation and Design Laboratory), Istanbul University-Cerrahpasa, Istanbul, Turkey.
| | - Ayse Sena Altun
- Bezmi Alem Vakif University, Faculty of Medicine, Istanbul, Turkey
| | - Omer Subasi
- Foot & Ankle Research and Innovation Lab (FARIL), Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Siddhartha Sharma
- Department of Orthopedics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Matthias Peiffer
- Department of Orthopaedics and Traumatology, Ghent University Hospital, Ghent, Belgium
| | - Soheil Ashkani-Esfahani
- Foot & Ankle Research and Innovation Lab (FARIL), Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Foot and Ankle Division, Department of Orthopaedic Surgery, Massachusetts General Hospital, Newton Wellesley Hospital, Harvard Medical School, Boston, MA, USA
| | - Christopher W DiGiovanni
- Foot & Ankle Research and Innovation Lab (FARIL), Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Foot and Ankle Division, Department of Orthopaedic Surgery, Massachusetts General Hospital, Newton Wellesley Hospital, Harvard Medical School, Boston, MA, USA
| | - Lorena Bejarano-Pineda
- Foot & Ankle Research and Innovation Lab (FARIL), Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Foot and Ankle Division, Department of Orthopaedic Surgery, Massachusetts General Hospital, Newton Wellesley Hospital, Harvard Medical School, Boston, MA, USA
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Karaismailoglu B, Nassour N, Duggan J, Peiffer M, Ghandour S, Bejarano-Pineda L, Ashkani-Esfahani S, Miller CP. Effect of sequential burr passes on osteotomy magnitude and calcaneal morphology in minimally invasive Zadek osteotomy. Foot Ankle Surg 2024; 30:150-154. [PMID: 37951779 DOI: 10.1016/j.fas.2023.10.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 09/29/2023] [Accepted: 10/26/2023] [Indexed: 11/14/2023]
Abstract
PURPOSE This study aimed to evaluate the impact of each burr pass on degree of correction, gap size and calcaneal morphology in MIS Zadek osteotomy. METHODS MIS Zadek osteotomy was performed on ten cadaveric specimens using a 3.1 mm Shannon burr. After each burr pass, the osteotomy gap was manually closed, and the subsequent burr passes were carried out with the foot held in dorsiflexion, which was repeated five times. Lateral X-rays were taken before and after each burr pass. Two independent reviewers measured the dorsal calcaneal length after each burr passage, as well as changes in several calcaneal parameters including X/Y ratio, Fowler Philip angle, and Böhler angle. RESULTS The average decrease in dorsal calcaneal cortical length with each burr pass was as follows: 2.6 ± 0.9 mm at the 1st pass, 2.4 ± 1 mm at the 2nd pass, 2 ± 1 mm at the 3rd pass, 1.6 ± 1 mm at the 4th pass, and 1.4 ± 0.7 mm at the 5th pass. The Fowler Philip and Böhler angles consistently decreased while the X/Y ratio consistently increased following each consecutive burr pass. Interobserver reliability analysis demonstrated good agreement for all parameters. CONCLUSION The results revealed the trends of length and anatomical changes in the calcaneus with each burr pass. On average, a dorsal wedge resection of 10 mm was achieved after 5 burr passes. This data can aid surgeons in determining the optimal number of burr passes required for a particular amount of resection, ensuring the attainment of the desired patient-specific surgical outcome.
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Affiliation(s)
- Bedri Karaismailoglu
- Foot & Ankle Research and Innovation Laboratory (FARIL), Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Department of Orthopaedics and Traumatology, Istanbul University-Cerrahpasa, Istanbul, Turkey; CAST (Cerrahpasa Research, Simulation and Design Laboratory), Istanbul University-Cerrahpasa, Istanbul, Turkey.
| | - Nour Nassour
- Foot & Ankle Research and Innovation Laboratory (FARIL), Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Jessica Duggan
- Department of Orthopaedics, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Matthias Peiffer
- Foot & Ankle Research and Innovation Laboratory (FARIL), Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Department of Orthopaedics and Traumatology, Ghent University Hospital, Ghent, Belgium
| | - Samir Ghandour
- Foot & Ankle Research and Innovation Laboratory (FARIL), Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Lorena Bejarano-Pineda
- Foot & Ankle Research and Innovation Laboratory (FARIL), Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Soheil Ashkani-Esfahani
- Foot & Ankle Research and Innovation Laboratory (FARIL), Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Christopher P Miller
- Foot & Ankle Research and Innovation Laboratory (FARIL), Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Department of Orthopaedics, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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Moran C, Tourné Y. Posterior Heel Pain in Cavovarus Foot: How to Approach It. Foot Ankle Clin 2023; 28:775-789. [PMID: 37863534 DOI: 10.1016/j.fcl.2023.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2023]
Abstract
When a patient presents with posterior heel pain on the background of a cavovarus foot, there are many different aspects to take into account. The morphology of the foot and the specific cause of the patient's pain lead the practitioner to alter the treatment appropriately. Some patients should only receive physiotherapy, but the majority should receive more invasive treatments, including calcaneal osteotomies or tendon debridement, depending on their particular presentation and pathology. This review examines the various different facets of posterior heel pain that must be dealt with and the most up-to-date treatments for the same.
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Affiliation(s)
- Conor Moran
- Centre Osteo Articulaires des Cèdres, 5 Rue des Tropiques Echirolles 38130, France
| | - Yves Tourné
- Centre Osteo Articulaires des Cèdres, 5 Rue des Tropiques Echirolles 38130, France.
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Black AT, So E, Combs A, Logan D. The Zadek Osteotomy for Surgical Management of Insertional Achilles Tendinopathy: A Systematic Review. Foot Ankle Spec 2023; 16:437-445. [PMID: 37083218 DOI: 10.1177/19386400231162411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/22/2023]
Abstract
BACKGROUND The calcaneal dorsal closing wedge osteotomy, otherwise known as the Zadek or Keck and Kelly osteotomy, is used to treat insertional Achilles tendinopathy. The purpose of this study is to investigate the clinical outcomes affiliated with the Zadek technique for insertional Achilles tendinopathy (IAT) as reported in the literature. METHODS An English literature search on PubMed was performed yielding 8 level IV retrospective case series. RESULTS The weighted mean of preoperative and postoperative Victorian Institute of Sports Assessment-Achilles Questionnaire (VISA-A) scores was 52.7 and 87.8, respectively. The weighted mean of preoperative and postoperative American Orthopaedic Foot and Ankle Society (AOFAS) scores was 56.3 and 92.9, respectively. Majority of the reported complications were minor events, including symptomatic hardware (2.8%; n = 7/247), sural nerve paresthesia (2%; n = 5/247), and superficial infection (3.2%; n = 8/247). There was 1 reported event of hardware failure resulting in re-operation. Deep vein thrombosis occurred at a rate of 0.8% (n = 2/247), complex regional pain syndrome at 0.4% (n = 1/247) and nonunion at a rate of 1.2% (n = 3/247). CONCLUSION The Zadek osteotomy is a viable option for insertional Achilles tendinopathy based on significantly improved outcome measures and minor complication rates. LEVEL OF EVIDENCE 4.
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Affiliation(s)
| | - Eric So
- Bryan Health, Lincoln, Nebraska
| | - Austin Combs
- Foot and Ankle Specialists of Central Ohio, Newark, Ohio
| | - Daniel Logan
- Foot and Ankle Specialists of Central Ohio, Newark, Ohio
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Nakajima K. Minimally invasive surgeries for insertional Achilles tendinopathy: A commentary review. World J Orthop 2023; 14:369-378. [PMID: 37377992 PMCID: PMC10292061 DOI: 10.5312/wjo.v14.i6.369] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 04/26/2023] [Accepted: 05/09/2023] [Indexed: 06/19/2023] Open
Abstract
Studies of minimally invasive surgery for insertional Achilles tendinopathy are limited. To establish this surgery, the following techniques must be minimally invasive: Exostosis resection at the Achilles tendon insertion, debridement of degenerated Achilles tendon, reattachment using anchors or augmentation using flexor hallucis longus (FHL) tendon transfer, and excision of the posterosuperior calcaneal prominence. Studies on these four perspectives were reviewed to establish minimally invasive surgery for insertional Achilles tendinopathy. Techniques for exostosis resection were demonstrated in one case study, where blunt dissection around the exostosis was performed, and the exostosis was resected using an abrasion burr under fluoroscopic guidance. Techniques for debridement of degenerated Achilles tendon were demonstrated in the same case study, where the space left after resection of the exostosis was used as an endoscopic working space, and the degenerated Achilles tendon and intra-tendinous calcification were debrided endoscopically. Achilles tendon reattachment techniques using suture anchors have been demonstrated in several studies. However, there are no studies on FHL tendon transfer techniques for Achilles tendon reattachment. In contrast, endoscopic posterosuperior calcaneal prominence resection is already established. Additionally, studies on ultrasound-guided surgeries and percutaneous dorsal wedge calcaneal osteotomy as minimally invasive surgery were reviewed.
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Affiliation(s)
- Kenichiro Nakajima
- Center for Foot and Ankle Surgery, Department of Orthopedic Surgery, YashioCentral General Hospital, Yashio-shi 340-0814, Saitama, Japan
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14
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Xu Y, Haider ZA, Karuppiah V, Dhar S. Zadek Osteotomy, a Good Treatment Option for Refractory Haglund's Deformity. Cureus 2023; 15:e39497. [PMID: 37378187 PMCID: PMC10292067 DOI: 10.7759/cureus.39497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/25/2023] [Indexed: 06/29/2023] Open
Abstract
INTRODUCTION Haglund's deformity (a prominence in the posterosuperior aspect of the calcaneum) is a known cause of posterior heel pain. Surgery is reserved for patients after failed conservative treatment. Zadek osteotomy is a dorsal-closing wedge osteotomy that reduces the posterior heel prominence. Zadek osteotomy is becoming a favored procedure, however, there are still relatively few studies focusing on patient-reported outcomes. Our main aim was to assess patient-reported outcomes following the Zadek osteotomy in refractory Haglund's deformity. Our secondary aim was to evaluate the correlation between patient outcomes and changes in their pre and postoperative Fowler-Philip and calcaneal pitch angles. METHODS We conducted a retrospective review of 19 patients (20 heels) who underwent Zadek osteotomy by a single surgeon at a tertiary hospital over six years. Patient-reported outcomes were collected preoperatively and at 12 months postoperatively using the validated Manchester-Oxford foot questionnaire (MOXFQ) scoring system. We also calculated the difference in their pre and postoperative Fowler-Philip angles and calcaneal pitch using the picture archiving communication system. RESULTS There was an average improvement of 108 points in the MOXFQ score at 12 months (P<0.05). There was no statistically significant change in calcaneal pitch. However, the Fowler-Phillip angle dropped with an average of 11.4 º (P<0.05). A decrease in the Fowler-Philip angle does improve patient-related outcome measurement scores, however, the relationship is not directly proportional with "r" measured at 0.23. CONCLUSION Our results show that Zadek osteotomy is a useful procedure to consider in patients with symptomatic refractory Haglund's deformity, with an improvement in patient outcomes at 12 months. However, further studies are needed to give stronger evidence for the efficacy of this procedure and its radiological correlations.
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Affiliation(s)
- Yiteng Xu
- Trauma and Orthopaedics, Torbay Hospital, Torbay and South Devon NHS Foundation Trust, Torquay, GBR
| | - Zulfiqar A Haider
- Trauma and Orthopaedics, Torbay Hospital, Torbay and South Devon NHS Foundation Trust, Torquay, GBR
| | - Vail Karuppiah
- Trauma and Orthopaedics, Nottingham City Hospital, Nottingham University Hospitals NHS Trust, Nottingham, GBR
| | - Sunil Dhar
- Trauma and Orthopaedics, Nottingham City Hospital, Nottingham University Hospitals NHS Trust, Nottingham, GBR
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Hembree WC, Tarka MC, Pasternack JB, Mathew SE, Guyton GP. What's New in Foot and Ankle Surgery. J Bone Joint Surg Am 2023; 105:737-743. [PMID: 36888693 DOI: 10.2106/jbjs.22.01382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/10/2023]
Affiliation(s)
- Walter C Hembree
- Department of Orthopaedic Surgery, MedStar Union Memorial Hospital, Baltimore, Maryland
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16
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Minimally Invasive Foot and Ankle Surgery: A Primer for Orthopaedic Surgeons. J Am Acad Orthop Surg 2023; 31:122-131. [PMID: 36656273 DOI: 10.5435/jaaos-d-22-00608] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 11/13/2022] [Indexed: 01/20/2023] Open
Abstract
There is rapidly growing interest in minimally invasive surgery (MIS) of the foot and ankle. Technological advances, specifically with the advent of low-speed high-torque burrs, have enabled the expansion of MIS techniques. Accordingly, there is growing literature reporting excellent outcomes of MIS surgery to address many different pathologies of the foot and ankle. MIS techniques are particularly useful for conducting percutaneous osteotomies and bony débridement. These can be used to address bunion deformity, hammertoes, metatarsalgia, bunionette deformity, bone spurs, and hindfoot deformity. A detailed understanding of the technology, equipment, and techniques is crucial to safely conduct MIS of the foot and ankle. When done safely, MIS provides favorable outcomes with an expedited recovery and limited complications.
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Mazura M, Goldman T, Stanislav P, Kachlik D, Hromadka R. Calcaneal osteotomy due to insertional calcaneal tendinopathy: preoperative planning. J Orthop Surg Res 2022; 17:478. [PMID: 36335392 PMCID: PMC9636787 DOI: 10.1186/s13018-022-03359-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 10/11/2022] [Indexed: 11/08/2022] Open
Abstract
Purpose Dorsal closing wedge calcaneal osteotomy (DCWCO) is indicated in patients with insertional tendinopathy of the calcaneal (Achilles) tendon. The Chauveaus-Liet’s (CL) angle is represented by the difference between the angle of verticalization (α) and morphological angle (β) of the calcaneus (CL angle = α − β). The purpose of the study was to assess whether the DCWCO affects the Chauveaus-Liet’s angle. Methods The study included 12 patients indicated to DCWCO. Three directions of close wedge osteotomy were designed for each patient—horizontal, vertical and in the middle type of osteotomy and a virtual osteotomy was created in each of them in the ABAQUS system in cooperation with Czech Technical University. The most used directions of osteotomy according to the available literature were used. We evaluated α and β angles before and after osteotomy, changes of the length plantar aponeurosis and the elevation of distal insertional point of the calcaneal tendon. The changes of grades, median and standard deviation were observed. Results The change of the alfa angle was dependent on the direction of the osteotomy and the change of the beta angle was affected by the size of the osteotomy. The greatest elevation of the distal insertional point of the calcaneal tendon occurred in the horizontal type of the osteotomy. Conclusion Our study shows that the more we want to reduce the tension in the calcaneal tendon, the more we have to perform an osteotomy horizontally. This study could serve as a preoperative guide for osteotomy planning.
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Affiliation(s)
- Matej Mazura
- grid.412826.b0000 0004 0611 0905First Department of Orthopaedics, First Faculty of Medicine, Charles University and Motol University Hospital, V Úvalu 84, 150 06 Prague 5, Czech Republic ,grid.4491.80000 0004 1937 116XDepartment of Anatomy, Second Faculty of Medicine, Charles University, V Úvalu 84, 150 06 Prague 5, Czech Republic
| | - Tomas Goldman
- grid.6652.70000000121738213Department of Mechanics, Bioemchanics and Mechatronics, Faculty of Mechanical Engineering, Czech Technical University in Prague, Technická 4, 166 07 Prague 6, Czech Republic
| | - Popelka Stanislav
- grid.412826.b0000 0004 0611 0905First Department of Orthopaedics, First Faculty of Medicine, Charles University and Motol University Hospital, V Úvalu 84, 150 06 Prague 5, Czech Republic
| | - David Kachlik
- grid.4491.80000 0004 1937 116XDepartment of Anatomy, Second Faculty of Medicine, Charles University, V Úvalu 84, 150 06 Prague 5, Czech Republic
| | - Rastislav Hromadka
- grid.412826.b0000 0004 0611 0905First Department of Orthopaedics, First Faculty of Medicine, Charles University and Motol University Hospital, V Úvalu 84, 150 06 Prague 5, Czech Republic
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Tourné Y, Francony F, Barthélémy R, Karhao T, Moroney P. The Zadek calcaneal osteotomy in Haglund's syndrome of the heel: Its effects on the dorsiflexion of the ankle and correlations to clinical and functional scores. Foot Ankle Surg 2022; 28:789-794. [PMID: 34794868 DOI: 10.1016/j.fas.2021.11.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Revised: 10/08/2021] [Accepted: 11/01/2021] [Indexed: 02/04/2023]
Abstract
The Zadek osteotomy is a therapeutic option in Haglund' syndrome for patients with a X/Y ratio measurement of the calcaneus under 2.5. We hypothesized that Zadek osteotomy would lead to improvement in ankle dorsiflexion and functional scores. Twenty-two patients (mean age: 48.5 years) with Haglund's syndrome underwent a Zadek osteotomy and were enrolled in a prospective study investigating the proposed hypothesis. Radiological measurements included the X/Y ratio and the pitch angle. Measurements of the dorsiflexion of the ankle, using a hand-made frame, were performed twice by 2 independent observers. Inter and intra classes correlations were calculated. Functional results were assessed using AOFAS, EFAS and EFAS sport. Correlation between ankle dorsiflexion and functional scores were determined using linear regression curves. Our hypothesis was validated with a mean improvement of dorsiflexion of 7.27° (54.98% improvement from pre-operative measurement) (p < 0.0001). Ankle dorsiflexion measurements were highly reproducible with an interclass correlation coefficient(ICC)> 0.95 (0.98-0.99). All mean values of functional scores were significantly improved(p < 0.05) [AOFAS (61.95-94), EFAS (14-21.82), EFAS sport (7.68-13.69)] and were strongly correlated to the dorsiflexion values with a coefficient of determination of 0.82 for AOFAS and EFAS and of 0.86 for EFAS sport, respectively. The mean values of X/Y ratio and pitch angle improved from pre to postoperative conditions, 2.18-2.75 and 28.95-19.77° (p < 0.05), respectively. The angle correction obtained from modifiying the shape of the calcaneus, due to the Zadek osteotomy, confirms it as a safe and reliable treatment, with improvements of both ankle dorsiflexion and functional scores.
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Affiliation(s)
- Yves Tourné
- Centre Ostéo-articulaire des Cèdres-Echirolles, France.
| | - Florent Francony
- Service de Chirurgie Orthopédique et Traumatologique, CH Métropole Savoie, Chambéry, France.
| | | | | | - Paul Moroney
- Sports Surgery Clinic, Santry, Dublin 9, Ireland.
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Yuen WLP, Tan PT, Kon KKC. Surgical Treatment of Haglund’s Deformity: A Systematic Review and Meta-Analysis. Cureus 2022; 14:e27500. [PMID: 36060327 PMCID: PMC9424834 DOI: 10.7759/cureus.27500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/31/2022] [Indexed: 11/16/2022] Open
Abstract
Posterosuperior calcaneal prominence, also known as Haglund’s deformity, can often lead to retrocalcaneal bursitis, a significant cause of posterior heel pain. Surgery is indicated for symptomatic patients, after a period of conservative treatment including analgesia, physiotherapy, activity, and shoe wear modification has failed. Surgical options include both open and endoscopic techniques, and typically involve excision of the retrocalcaneal bursa, resection of the calcaneal prominence, and debridement of the diseased Achilles tendon. This article aims to provide an evidence-based literature review for the surgical management of Haglund’s deformity. A comprehensive evidence-based literature review of the PubMed database conducted in July 2021 identified 20 relevant articles assessing the efficacy of surgical modalities for Haglund’s deformity. The 20 studies were assigned to a level of evidence (I-IV). Individual studies were reviewed to provide a grade of recommendation (A-C, I) according to the Wright classification in support of or against the surgical modality. Qualitative and quantitative analysis was performed for the 20 studies. The results show that both open and endoscopic surgical modalities are efficacious in the treatment of Haglund’s deformity, significantly improving functional outcome scores such as American Orthopaedic Foot & Ankle Society (AOFAS) scores and patient satisfaction post-operatively. Endoscopic surgery appears to have the advantage of shorter operative times, lower complication rates, and better cosmesis. More studies are required to further validate and optimize these surgical techniques.
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