Modified Zadek osteotomy without excision of the intratendinous calcific deposit is effective for the surgical treatment of calcific insertional Achilles tendinopathy

Biomechanical Changes to the Hindfoot After Zadek Osteotomy

BACKGROUND

Insertional Achilles tendinopathy (IAT) is a common source of heel pain in active adults and athletes. The Zadek osteotomy (ZO) is a calcaneal dorsal closing wedge osteotomy that has demonstrated clinical success as a treatment for IAT, purported to favorably improve tendon mechanics, decrease impingement, and decrease pressure within the retrocalcaneal bursa. The present study aims to evaluate the biomechanical effects of ZO on Achilles strain, position of the Haglund prominence relative to the Achilles insertion, and retrocalcaneal pressure.

METHODS

The ZO was performed on 10 fresh-frozen foot and ankle mid tibia-fibula cadaveric specimens. An osteotomy was performed using a 1-cm dorsal closing wedge procedure secured with a 7.0 mm cannulated screw. Point pressure sensor catheters and differential variable reluctance transducers were used to measure the retrocalcaneal pressure and Achilles strain, respectively, pre- and postosteotomy. Paired t-tests were utilized to detect statistical differences (P < .05).

RESULTS

After the ZO, the Haglund prominence was translated 9.9 mm anteriorly with respect to the insertion of the Achilles (P < .05) and the Achilles tendon insertion was translated 3.4 mm proximally (P < .05). The ratio of calcaneal length to greater tuberosity length, the X/Y ratio, increased from 2.56 to 3.52 with the osteotomy (P < .05). At maximum dorsiflexion, retrocalcaneal pressure decreased from 117 to 66 mm Hg (44%, P = .018). The Achilles strain changed from 0.00362 to 0.00436 in the anterior fibers (P = .484) and changed from 0.00467 to 0.00283 in the posterior fibers (P = .088).

CONCLUSION

Biomechanical testing in a cadaveric model demonstrates that the ZO decreased retrocalcaneal pressure, shifted the Achilles tendon insertion proximally, increased the X/Y ratio of the calcaneus, and did not significantly change the strain of the Achilles tendon.

CLINICAL RELEVANCE

Despite the clinical success demonstrated in recent literature, there are no biomechanical studies describing the effect of the ZO on the biomechanics of the hindfoot, and the mechanism of symptom relief of the ZO for IAT is not well understood. The present study measures two potential ZO effects relative to Haglund prominence by measuring retrocalcaneal pressure and displacement of the Achilles tendon with respect to the Haglund prominence, and measures one ZO effect relative to calcification of the tendon by measuring the Achilles tendon strain.

Ankle Muscle Strength and Gait Function After Dorsal Closing Wedge Calcaneal Osteotomy for Haglund Exostosis-Related Heel Pain

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.

Percutaneous vs Open Zadek Osteotomy for Treatment of Insertional Achilles Tendinopathy and Haglund's Deformity: A Systematic Review

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.

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.

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.

Failed Surgery for Achilles Tendinopathy

Treatments of Achilles tendinopathy continue to evolve. The body of literature is inadequate to provide a comprehensive guide to evaluation and treat failed surgeries. Issues related to failed surgical treatment may be divided into infection/wound issue, mechanical failure, and persistent pain. Awareness of the potential problems described in this article will allow surgeons to have a foundation in clinical assessment and making accurate diagnoses. Various surgical treatment options are available and should be executed carefully to treat individualized patient conditions.

Clinical results of the Keck and Kelly Wedge Osteotomy approach in Haglund's deformity: Minimum 3-year follow-up

BACKGROUND AND PURPOSE

The Haglund's deformity, which may be difficult to treat non-surgically, is caused by a prominent bone hump in the posterosuperior region of the calcaneus and may be associated with bursitis and foot pain. Many surgical treatments for resistant Haglund deformities have been described. Here, we evaluate the AOFAS scores, pain and other characteristics of patients undergoing removal of the dorsally based wedge from the posterior calcaneus with the Keck and Kelly procedure.

MATERIALS AND METHODS

The study included 20 patients who had undergone the Keck and Kelly procedure at our center, from 2011 to 2019, and had attended follow-up for at least three years. Analyses were performed retrospectively. Preoperative (immediately before surgery) and postoperative (at last assessment) American Orthopedic Foot and Ankle Society (AOFAS) and visual analog pain scale scores (VAS) were determined, and calcaneal inclination angles were radiologically measured. Additionally, calcaneal pitch angle (CPA), Fowler and Philip angle (FPA), and Bohler angle were recorded.

RESULTS

Fourteen patients were female, and six were male, mean age was 45.8 ± 8.1 years. AOFAS scores were significantly increased, whereas VAS scores were significantly decreased after surgery. Postoperative AOFAS scores were correlated with preoperative VAS, CPA, and FPA values. Preoperative VAS scores were correlated with CPA, FPA, and Bohler angle values. FPA and CPA values were correlated positively.

CONCLUSIONS

It was found that ankle functions improved, and pain levels decreased after Keck and Kelly Wedge Osteotomy was applied for the treatment of Haglund's deformity. CPA and FPA were associated with both pain levels and ankle function. The Keck and Kelly Wedge Osteotomy procedure appears to be a preferable approach for the surgical treatment of Haglund's deformity.