A Proposed Staging Classification for Minimally Invasive Management of Haglund's Syndrome with Percutaneous and Endoscopic Surgery

Endoscopic Calcaneoplasty in Haglund Disease: Surgical Technique, Clinical and Subjective Outcomes

BACKGROUND

During the last decade, arthroscopic procedures have been replacing open techniques in Haglund disease treatment because of their considerable advantages. Endoscopic calcaneoplasty is a technique that allows resection of posterosuperior calcaneal exostosis and retrocalcaneal bursitis. The objective of this article was to describe this technique and report its clinical and subjective outcome.

METHODS

A retrospective study was performed of consecutive patients undergoing endoscopic Haglund resection surgery between July 2014 and March 2020 at a single academic institution. All patients were surveyed in person about the level of pain (visual analog scale), its location (central, lateral, medial or diffuse), its relation with rest, or physical activity. Clinical evaluation was assessed using the hindfoot scale designed by the American Orthopaedic Foot & Ankle Society (AOFAS).

RESULTS

In this study, 14 endoscopic calcaneoplasties were performed in 14 patients, with an average follow-up of 40 months. The visual analog scale score improved from a preoperative average value of 9.07 to 1.8 after surgery (P > .0001). The AOFAS scale rose from 38.7 before surgery to 94.6 postoperative (P > .0001). Good subjective results were observed in 12 patients (85.7%), and all of them would have surgery again. There were no wound complications or infections. No patient required reoperation.

CONCLUSION

In this relatively small cohort, we found that endoscopic calcaneoplasty was associated with good clinical and subjective results with few complications.

Biomechanical consequences of Zadek osteotomy in insertional achilles tendinopathy: A virtual surgical simulation study

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.

Landmarks for a Minimally Invasive Approach for Haglund's Deformity: A Cadaveric Study

INTRODUCTION

Haglund's deformity is a posterosuperior calcaneal prominence often associated with a painful bursa and insertional Achilles tendinopathy. Endoscopic debridement has been previously described; however, the aim of this cadaveric study is to describe landmarks of a minimally invasive surgical (MIS) approach to Haglund's deformity.

METHODS

Twelve specimens were dissected to identify medial and lateral portals for minimally invasive burr placement and anchor placement. A standard ruler was used to measure the distance in millimeters from the medial and lateral neurovascular structures in relation to medial and lateral portals. A separate 7-cm longitudinal incision posterior to the lateral malleolus and a separate 7-cm longitudinal incision posterior to the medial malleolus were made to identify at-risk neurovascular structures.

RESULTS

The average distance from the sural nerve to the lateral portal was 25.7 mm (23-26). The mean distance from the lateral calcaneal branch of the sural nerve to lateral portal was 11.4 mm (10-12). The mean distance from the tibial nerve to the medial portal was 35.3 mm (35-36). Both the medial and lateral incisions were 9.3 mm from the calcaneal tuberosity.

CONCLUSION

The results indicate that the MIS approach to Haglund's deformity resection can be performed reliably without neurovascular compromise.

LEVELS OF EVIDENCE

Level IV.

Posterior Heel Pain in Cavovarus Foot: How to Approach It

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.

Endoscopic calcaneoplasty with gastrocnemius recession for Haglund's syndrome: Is it safe and effective? Results from a retrospective case series

BACKGROUND

Endoscopic calcaneoplasty (ECP) and gastrocnemius recession (GR) are procedures that have been described to effectively treat Haglund's deformity and insertional Achilles tendinopathy respectively. The purpose of our manuscript is to evaluate the efficacy and safety of ECP and GR with immediate weightbearing for the treatment of Haglund's deformity with mild to moderate insertional Achilles tendinopathy.

METHODS

We performed ECP coupled with GR on 14 patients with an average age of 52 years. All patients demonstrated < 50% tendinous degeneration on MRI. All were allowed weightbearing as tolerated in a CAM boot within the first post-operative week. AOFAS scores and plain film radiographic findings were collected pre-operatively and post-operatively.

RESULTS

The radiographic exam of the Fowler-Philip angle significantly improved from an average 60.1-40.7° (p < 0.001). The AOFAS ankle/hindfoot score significantly improved from an average 54.7-91.4 (p < 0.001). The average return to work was 7.5 weeks. There were two cases of temporary sural nerve paresthesia, and two cases of delayed wound healing.

CONCLUSIONS

This is the first mid-term study evaluating the outcomes of ECP with GR. The results of our study suggest that ECP with GR followed by immediate weightbearing is a safe and effective procedure for the treatment of Haglund's deformity and mild to moderate insertional Achilles tendinopathy.

The Zadek Osteotomy for Surgical Management of Insertional Achilles Tendinopathy: A Systematic Review

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.

Minimally invasive surgeries for insertional Achilles tendinopathy: A commentary review

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.

Clinical outcomes and complications of the Zadek calcaneal osteotomy in Insertional Achilles Tendinopathy: A systematic review and meta-analysis

BACKGROUND

The Zadek osteotomy, a dorsal closing wedge osteotomy of the calcaneus, has been described as a treatment option in patients with Insertional Achilles Tendinopathy (IAT) that have failed conservative management. The aim of this study was to evaluate the clinical outcomes and the complications of the Zadek for the management of IAT.

METHODS

PubMed, EMBASE and Cochrane Central Register of Controlled Trails (CENTRAL) were searched for all studies to November 2022. PRISMA guidelines were followed. The overall estimates of effect were presented as Weighted Mean Difference (WMD) and 95 % confidence intervals (CIs). Meta-analysis was conducted using the Review Manager Software (RevMan, Version 5.4).

RESULTS

Ten studies with 232 patients were included. Functional scores and pain levels were significantly improved after the Zadek osteotomy (p < 0.00001). There were a total of 22 complications reported in the included studies and they were all considered minor. The most common complications were superficial wound infection and sural nerve paraesthesia.

CONCLUSIONS

The Zadek osteotomy is a safe and effective procedure for patients with IAT. There are no well-designed randomized controlled trials in the literature assessing the outcomes of a Zadek osteotomy against alternate surgical treatments and future research should focus on this.

LEVEL OF EVIDENCE

II.

Minimally Invasive Foot and Ankle Surgery: A Primer for Orthopaedic Surgeons

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.

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

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.

Haglund's Deformity as a Cause of Acute Achilles Tendon Rupture: A Case Report

Achilles tendon rupture is a common problem affecting both high level and casual athletes. Haglund´s deformity is an abnormality of the postero-superior part of the calcaneus, which often leads to retro-calcaneal bursitis as well as thickening and inflammation of the calcaneal tendon, a combination of pathologies known as Haglund's syndrome. We report a rare case of a relapse Achilles tendon rupture in a 39-year-old professional handball player with a pronounced painful Haglund´s deformity treated with tendon debridement and reattachment using the Arthrex Speedbridge® system. This case report illustrates a rarely described operative and post-operative management of this unusual combination of Achilles tendon rupture and Haglund´s deformity.

The Zadek calcaneal osteotomy in Haglund's syndrome of the heel: Clinical results and a radiographic analysis to explain its efficacy

Local debridement or decompression of the posterior heel in Haglund's syndrome yields variable results. This condition is sometimes due to an excessively long calcaneus rather than simply a large posterosuperior bony prominence. Failure to address this abnormality may explain the poor results in some series. We recently published a new measurement (the X/Y ratio) which, combined with the calcaneal pitch angle, assesses the abnormality of the shape of the calcaneus. The Zadek osteotomy strongly modifies that shape. We retrospectively reviewed 50 patients treated by a Zadek osteotomy at a mean 7 years follow-up using the AOFAS ankle-hindfoot score, the VISA-A score and Tegner scale. We measured only the X/Y ratio and the calcaneal inclination angle, as the classically described radiographic measurements in Haglund's syndrome are unreliable. We then assessed the condition of the distal end of the Achilles tendon with an MRI. Our results demonstrate excellent outcomes(40/50, 80%) following Zadek osteotomy and correspond to the change in pre- and post-operative measurements, especially the X/Y ratio. An algorithm using those geometrical measurements of the calcaneus is proposed for decision making in Haglund's syndrome. Level of clinical evidence: Level 3.

Outcomes of Percutaneous Calcaneoplasty for Insertional Achilles Tendon Problems

BACKGROUND

Percutaneous procedures have been used recently to treat insertional Achilles tendon problems. The present study reports our results of this treatment approach.

METHODS

Patients undergoing percutaneous calcaneoplasty for insertional Achilles tendon problems were retrieved. Patients completed the visual analog scale (VAS) for pain and the Victorian Institute of Sports Assessment-Achilles (VISA-A) questionnaire before the operative procedure and at the last follow-up. At the last follow-up, we asked the patients whether they were completely satisfied, moderately satisfied, or unsatisfied after the procedure. Complications were also recorded.

RESULTS

A total of 27 patients were enrolled. The average follow-up was 26.5 months (range 6-68). The mean age of patients was 56.2 years (24-82). The mean VAS score before surgery was 8.1 ± 0.9 decreasing by the last follow-up to 2.4 ± 2.3 (P < .0001). The mean VISA-A score improved from 20.7 ± 5.4 to 75.7 ± 25.5 at last follow-up, an improvement of 55% (P < .0001). At the last follow-up, 84.5% (22 of 27) patients were completely satisfied with the procedure, 7.4% (2 of 27) moderately satisfied, and 11.1% (3 of 27) were not satisfied. These last 3 patients presented recurrence of symptoms, requiring revision surgery.

CONCLUSION

For the selected patients, we found percutaneous calcaneoplasty to be an effective treatment for insertional Achilles tendon problems.

LEVEL OF EVIDENCE

Level III, retrospective study.

Endoscopic calcaneoplasty for the treatment of Haglund's deformity provides better clinical functional outcomes, lower complication rate, and shorter recovery time compared to open procedures: a systematic review

PURPOSE

The aim of this research is to report the clinical outcome following surgical correction of Haglund's deformity summarising different surgical strategies and comparing clinical outcomes, failures, complications and return to activities of patients underwent open and endoscopic techniques.

METHODS

A systematic search of the literature was conducted using eight different databases. Thirty-five studies were included in the systematic review. A total of 1260 ankles of 1147 patients were grouped in accordance with the surgical approach (open, endoscopic, or percutaneous).

RESULTS

The overall mean age was 44.8 ± 8.2 (range 14.9-82) years with a mean follow-up of 30.9 ± 17.1 (range 3-132) months. Analysis of clinical outcomes of open and endoscopic techniques demonstrated significant differences of AOFAS (87.1 ± 5.9 versus 90.7 ± 4.2 points; P < 0.001), complications (15.5% versus 4.1%; P < 0.001), failures (6.0% versus 1.2%; P < 0.001), time to return to daily activities (17.2 ± 9.3 versus 6.3 ± 1.0 weeks; P < 0.001) and time to return to sport (20.7 ± 3.3 versus 11.9 ± 0.3 weeks; P < 0.001) in the studies that reported these specific outcome measures.

CONCLUSION

Surgical correction of Haglund's deformity provides overall good clinical results and high subjective satisfaction. Endoscopic procedures demonstrated better final AOFAS, a lower rate of complications and failures, and shorter recovery time when compared to open techniques.

LEVEL OF EVIDENCE

Level IV.

Surgical treatment for insertional Achilles tendinopathy and retrocalcaneal bursitis: more than 1 year of follow-up

OBJECTIVE

To analyse the imaging changes in bone marrow oedema of the calcaneal prominence, retrocalcaneal bursa and degenerative Achilles tendon after the surgical treatment of insertional Achilles tendinopathy (IAT).

METHODS

This retrospective study analysed patients with IAT and retrocalcaneal bursitis that were diagnosed based on their symptoms and radiographic and magnetic resonance imaging (MRI) examinations. For patients that had received 3 months of conservative treatment but still presented with symptoms, arthroscopic debridement of the retrocalcaneal bursa and resection of calcaneal prominence were undertaken. Patients with degeneration of the Achilles tendon underwent debridement of Achilles tendon calcification with an open incision. The last follow-up included radiographic and MRI imaging, Visual Analogue Scale (VAS) pain scores and American Orthopedic Foot and Ankle Society (AOFAS)-Ankle and Hindfoot scores.

RESULTS

Thirty patients were included (mean ± SD follow-up, 3.1 ± 0.5 years). The VAS pain and AOFAS-Ankle and Hindfoot scores were significantly improved after surgery. MRI showed that bone marrow oedema of the calcaneal prominence and the retrocalcaneal bursa was significantly reduced compared with preoperative values. There was no significant change in the high signal area of the IAT.

CONCLUSION

Surgical treatment of IAT and retrocalcaneal bursitis effectively alleviated local pain and restored function.

The Utility of SPECT/CT in Diagnosing Haglund Syndrome With Bone Scintigraphy

Haglund syndrome-the combination of Haglund's deformity, retrocalcaneal bursitis, and achilles tendinopathy-is a common cause of hind foot pain in adults; however, diagnosis on planar scintigraphy can be challenging. We present a case of Haglund syndrome and show the key role that SPECT/CT can play in its diagnosis.

[Research progress in Achilles tendinopathy]

OBJECTIVE

To explore the classification, diagnosis, and clinical treatment of Achilles tendinopathy.

METHODS

The literature about Achilles tendinopathy at home and abroad was reviewed. The research results of classification and terms, imaging diagnosis, and clinical treatment of Achilles tendinopathy were summarized.

RESULTS

The classification and name of Achilles tendinopathy are not completely unified, and the concept is vague, the cause of disease is not clear. There are many treatment plans, but there is no effective evidence-based medicine research.

CONCLUSION

The diagnosis and treatment of Achilles tendinopathy is complicated. According to the characteristics of Achilles tendon anatomy and etiology, the classification and definition of Achilles tendinopathy need to be further studied in order to guide clinical treatment more effectively and facilitate experience exchange and learning.

Achilles Tendon Lesions - Part 1: Tendinopathies

Calcaneal tendon injuries are extremely common in the general population and in orthopedics routine care. Its increasing incidence, which is motivated by an aging population, improved access to the health care system, increased prescription of continuous-use medication, erratic participation in sports and other factors, has had a direct impact on society. Consolidated treatment options for tendinopathies lack quality scientific support for many modalities. New therapies have emerged to enhance nonsurgical approach outcomes and to reduce the number of patients requiring surgery. Although these operative procedures provide good pain relief and functional outcomes, they are costly and may lead to complications.

Percutaneous Zadek osteotomy for the treatment of insertional Achilles tendinopathy

BACKGROUND

Insertional Achilles tendinopathy (IAT) is a challenging common lower extremity disorder, despite several treatment options described in literature. Open dorsal closing wedge calcaneal osteotomy or Zadek Osteotomy (ZO), for the treatment of the IAT has good clinical results but a high rate of postoperative complications. The purpose of this study is to describe percutaneous ZO for the treatment of the IAT and to evaluate its impact on the clinical and functional postoperative outcomes.

METHODS

Twenty-six consecutive patients presenting with unilateral IAT refractory to nonoperative measures were treated with percutaneous ZO. Visual Analogue Scale (VAS) and Foot Function Index Score (FFI) were recorded preoperatively and at final follow-up visit (12±3) months. Postoperative complications, satisfaction, and relief of the pain were also recorded.

RESULTS

The percutaneous ZO showed a significant improvement (p<0.0001) in preoperative to postoperative FFI (from 65±9 to 8±12) and VAS (from 9±1 to 1±2). Two postoperative complications (8%) were observed: a case of symptomatic non-union and hardware pain, both in healthy patients. The overall rate of satisfaction after surgery was (92%). The relief from pain was achieved after an average period of 12 weeks.

CONCLUSIONS

ZO is a safe and effective procedure for the treatment of IAT. The use of a minimally invasive surgical approach is associated with excellent pain reduction (VAS score) and improved clinical function (FFI score). When compared to the open surgical approach, the percutaneous ZO may decrease recovery time and postoperative complications.

LEVEL OF EVIDENCE

III, retrospective case series.

Transtendinous approach calcaneoplasty versus endoscopic calcaneoplasty for Haglund's disease

PURPOSE

In this study, we performed a comparison between open calcaneoplasty through transtendinous approach and endoscopic calcaneoplasty for Haglund's disease.

METHODS

A retrospective review was performed of patients who had undergone either a calcaneoplasty with transtendinous approach or endoscopic for Haglund's disease from three centres. Inclusion criteria were patients with Haglund's disease confirmed radiographically, neutral alignment of the hindfoot and at least one year of follow-up. Patients were excluded in case of ipsilateral ankle osteoarthritis or other neighbouring joints, previous foot surgery, hindfoot malalignment and marked calcific insertional Achilles tendinosis. A chart review was performed to collect demographic data, including age, sex and body mass index (BMI). Functional outcome analysis included the Foot Function Index, AOFAS score and VAS for pain pre-operatively and post-operatively at the last follow-up. This patient-reported outcome scores were used in the native language of each patient (Italian).

RESULTS

Clinical and functional outcomes were collected from 54 patients (28 heels treated by open technique and 26 heels treated by endoscopic technique). In the open group, the AOFAS score improved from a pre-operative value of 65.67 ± 10.09 points to a value of 91.78 ± 9.67 points at the last follow-up (P < 0.05). In the endoscopic group, the AOFAS score improved from a pre-operative value of 66.69 ± 7.19 points to a value of 93.69 points ± 10.04 at the last follow-up (P < 0.05). The VAS and the FFI (Disability and Pain) scores were also improved significantly in both groups at the final follow-up evaluation (P < 0.001). Comparing the final follow-up post-operative clinical scores between the two groups, there was no difference in the AOFAS, VAS or the FFI scores between the two groups. No major complications were recorded, except for one Achilles tendon tear after open calcaneoplasty. The satisfaction rate was similar for both techniques.

CONCLUSIONS

Both techniques provided good clinical outcomes with a low rate of complications.

[Advance of diagnosis and treatment of Haglund syndrome]

OBJECTIVE

To review the current research on the diagnosis and treatment of Haglund syndrome.

METHODS

The domestic and foreign literature about Haglund syndrome in recent years was extensively reviewed to summarize and analyze the etiology, anatomy, clinical manifestations, diagnosis, and treatment of Haglund syndrome.

RESULTS

The etiology of Haglund syndrome is not very clear, and it may be related to local friction and high gastrocnemius muscle tension, and there may be a certain genetic tendency. The local anatomy is more complex and there are many adjacent tissue structures. Haglund malformation may cause the impingement of the posterior heel bursa and Achilles tendon insertion, lead to wear of the posterior heel bursa and the Achilles tendon insertion, and finally result in pain. The FPA (Fowler-Philipp angle), CPA (calcaneal pith angle), PPL (parallel pitch lines), CLA (Chauveaux-Liet angle), and X/Y ratios (ratio of total calcaneal length to calcaneal tuberosity length) measured on X-ray film can be used for the diagnostic measurement of Haglund malformation. Treatment includes conservative and surgical treatment (open Haglund ostectomy, dorsal closed wedge osteotomy of the calcaneus, and arthroscopic Haglund osteotomy).

CONCLUSION

Both open and arthroscopic Haglund ostectomy and dorsal closed wedge osteotomy of the calcaneus can achieve satisfactory results, but minimally invasive treatment is the current development trend. Surgeons should pay attention to the management of the calcification of Achilles tendon insertion and reconstruction of Achilles tendon insertion.

Biomechanical Comparison of Achilles Tendon Pullout Strength Following Midline Tendon-Splitting and Endoscopic Approaches for Calcaneoplasty

BACKGROUND

Calcaneoplasty is a common procedure performed for the management of Haglund's syndrome when nonoperative management fails. Midline tendon-splitting and endoscopy are 2 common approaches to calcaneoplasty. Studies have suggested that an endoscopic approach may allow earlier return to activity and superior outcomes, but there are no biomechanical or clinical studies to validate these claims. The goal of this study was to quantify and compare Achilles tendon pullout strength following midline tendon-splitting and endoscopic calcaneoplasty in cadaveric specimens.

METHODS

Twelve match-paired cadaveric specimens were randomly divided into 2 groups: endoscopic and midline tendon-split. Following calcaneoplasty, fluoroscopy was used to match bone resection and the Achilles was loaded to failure in a mechanical testing system. A paired-samples t test was conducted to compare bone resection height, bone resection angle, load to failure, and mode of failure.

RESULTS

The endoscopic approach yielded a 204% greater postsurgical pullout strength for the Achilles tendon than the midline tendon-split (1368 ± 370 N vs 450 ± 192 N, respectively) (P < .05). There were no differences in resection angle or resection height. All specimens failed due to bone or tendon avulsion.

CONCLUSION

Endoscopic calcaneoplasty had more than 3 times greater pullout strength than the midline tendon-splitting approach.

CLINICAL RELEVANCE

This may allow earlier return to functional rehabilitation following endoscopic calcaneoplasty, but further studies are needed to determine if these differences are clinically significant. Further understanding of the time-zero biomechanics following calcaneoplasty may provide guidance regarding postoperative management with respect to surgical approach.

Surgical Strategies for the Treatment of Insertional Achilles Tendinopathy

Insertional Achilles tendinopathy is one of the most common Achilles tendon disorders and often results in substantial heel pain and functional disability. There is consensus that treatment of insertional Achilles tendinopathy should start with nonoperative modalities. Surgery should be reserved for patients who fail exhaustive conservative treatment for a period of 3 months to 6 months and include débridement of insertional calcifications. Intratendinous degenerative tissue should be débrided and any Haglund deformity resected. Different surgical techniques have been described for reattachment of the distal Achilles tendon. The authors' preferred surgical technique includes the knotless double-row footprint reconstruction. Postoperative complications are not rare.

Minimally Invasive and Endoscopic Treatment of Haglund Syndrome

Haglund syndrome is a triad of posterosuperior calcaneal prominence (Haglund deformity), retrocalcaneal bursitis, and insertional Achilles tendinopathy. The sources of pain include the posterior calcaneal wall cartilage, retrocalcaneal and subcutaneous adventitial bursa, and the Achilles tendon. Resection of the posterosuperior calcaneal tubercle, bursectomy, excision of the Achilles tendon pathology, reattachment of the Achilles tendon, gastrocnemius aponeurotic recession, and flexor hallucis longus transfer have been proposed as surgical treatment options. All of them can be performed endoscopically or under minimally invasive approaches.

[Insertional Achilles tendinopathy : Differentiated diagnostics and therapy]

Achilles tendinopathy at the calcaneal insertion is classified into insertional tendinopathy, retrocalcaneal and superficial bursitis. The aim of this study was to present the current evidence on conservative and surgical treatment of insertional tendinopathy of the Achilles tendon. Conservative first-line therapy includes reduction of activity levels, administration of non-steroidal anti-inflammatory drugs (NSAID), adaptation of footwear, heel wedges and orthoses or immobilization. In addition, further conservative therapy options are also available. Eccentric stretching exercises should be integral components of physiotherapy and can achieve a 40% reduction in pain. Extracorporeal shock wave therapy has been shown to reduce pain by 60% with a patient satisfaction of 80%. Due to the limited evidence, injections with platelet-rich plasma (PRP), dextrose (prolotherapy) or polidocanol (sclerotherapy) cannot currently be recommended. Operative therapy is indicated after 6 months of unsuccessful conservative therapy. Open debridement allows all pathologies to be addressed, including osseous abnormalities and intratendinous necrosis. The success rate of over 70% is contrasted by complication rates of up to 40%. The Achilles tendon should be reattached, if detached by >50%. No valid data are available for the transfer of the tendon of the flexor hallucis longus (FHL) muscle but it is frequently applied in cases of more than 50% debridement of the diameter of the Achilles tendon. Lengthening of the gastrocnemius muscle cannot be recommended because insufficient data are available. Tendoscopy is a promising treatment option for isolated retrocalcaneal bursitis and has shown similar success rates to open debridement with significantly lower complication rates.

Contribution of a new radiologic calcaneal measurement to the treatment decision tree in Haglund syndrome

INTRODUCTION

In Haglund syndrome, standard radiologic measurements lack specificity and reliability in assessing etiologic morphologic calcaneal abnormalities. We report a simple X/Y ratio to measure posterior calcaneal length, where X is calcaneal length on lateral weight-bearing view and Y is greater tuberosity length.

OBJECTIVE

To compare this new parameter against the radiologic gold standard in a group of Haglund patients and a healthy control group.

HYPOTHESIS

Measuring this ratio significantly distinguishes between Haglund patients and healthy subjects.

MATERIAL AND METHODS

A retrospective study included 50 Haglund syndrome patients and 30 healthy controls. Standard measurements (Fowler-Philipangle, Chauveaux-Liet angle, Ruch pitch, Heneghan-Pavlov test) and X/Y ratio were calculated twice by 2 independent observers. Intra- and inter-observer correlations were calculated, as were the specificity and sensitivity of the various parameters, with a ROC curve to establish the X/Y threshold.

RESULTS

All measurements were reproducible on intra- and inter-observer testing. There were no significant inter-group differences in standard measurement specificity or sensitivity. The Haglund group showed significantly lower X/Y ratio (2.07) than controls (2.70; p<0.0001), with a cut-off at 2.5. Threshold sensitivity in confirming Haglund syndrome was 100% (p<0.0001) and specificity 95% (p<0.0001).

DISCUSSION

This new parameter measures the length of the calcaneus and its greater tuberosity. It is more reliable and reproducible in terms of sensitivity and specificity than standard measurements in Haglund syndrome. The 2.5 ratio threshold can guide surgical decision-making.

LEVEL OF EVIDENCE

III.

Modified Bunnell suture expands the surgical indication of the treatment of Haglund's syndrome heel pain with endoscope

The aim of the present study was to develop a method which can solve the problem of partial tearing of the Achilles tendon insertion caused by the debridement for Haglund's syndrome using endoscopy-assisted percutaneous repair. Seven patients with Haglund's syndrome were prospectively recruited. All 7 patients (3 female, 4 male) had intratendinous calcifications. Preoperative diagnosis was made according to the clinical symptoms and diagnosis, medical examination results, plain film radiographs, and magnetic resonance imaging. The patients whose average age was 35.2 years, had experienced symptoms and were treated by conservative methods for 12-24 months (average 17.1 months). All 7 cases were treated with debridement of Achilles tendon insertion site with a standard 4.0 mm bur and underwent repair treatment with a modified Bunnell suture method under direct visualization using arthroscopy. The American Orthopaedic Foot and Ankle Society (AOFAS) score and the changes of the patient's parallel pitch lines were used to evaluate and assess the results. The follow-up period averaged 22 months. The lateral X-ray film after operation of all the heels of the patients showed that sufficient osseous planning of all the patients was completed. None of the patients converted to conventional open surgery. The average AOFAS scores of the 7 cases were improved significantly at final follow-up compared to pretherapy (P<0.005). The results of 5 of the 7 cases were excellent, 2, were good, and 0 was fair or poor. None of the cases had permanent nerve injuries, wound infections or Achilles tendon avulsion. Our study is a supplement of endoscopic repairing and strengthening of the Achilles tendon. The advantages and clinical significance of endoscopy during the treatment of Haglunds syndrome under the premise of strict control of operation indications were further verified.