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.

Heel Pain Management in Haglund's Deformity Targeting Sural Nerve Branches under Ultrasound Guidance: Case Report

Introduction

Haglund's deformity is an abnormality of the bone and soft tissue of the foot, also known as retrocalcaneal exostosis, Mulholland deformity, and "pump bump". The etiology is not well known. Probable causes include a tight Achilles tendon, a high arch of the foot, and hereditary. The clinical features consist of pain at the posterior aspect of the heel which is predominantly present when the patient begins to walk after a period of rest or inactivity.

Case Report

We report a case of a 60-year-old teacher with left heel pain for 3 years, unable to stand or walk for more than 15 min due to pain. We diagnosed him as a case of Haglund's deformity and treated him with ultrasound-guided injections targeting the superficial branches of the sural nerve. This case report illustrates a rarely described modality for the management of heel pain due to Haglund's deformity. Targeting superficial branches of the Sural nerve under ultrasound guidance can act as a superior treatment modality for the management of heel pain due to Haglund's deformity.

Conclusion

Haglund's deformity is a cause of pain in the hindfoot that should be taken into account in the differential diagnosis of any patient presenting with heel pain. Ultrasonography has proved to be an important cost-effective tool in the diagnosis and management of various ankle pathologies like Haglund's deformity, thereby reducing the sole dependence on surgical management. Targeting the superficial (cutaneous) branches of the sural nerve can give satisfactory long-term relief of heel pain in patients with Haglund deformity.

The Addition of a Krackow Rip Stop Suture Augment After Achilles Tendon Debridement for Insertional Achilles Tendinopathy: A Biomechanical Study

BACKGROUND

In the operative treatment of insertional Achilles tendinopathy, the Achilles tendon is often released from its insertion to allow for adequate debridement of pathologic tissue. The use of a double row suture anchor construct has become increasingly favorable among surgeons after Achilles tendon debridement. This study hypothesized that the addition of a Krackow rip stop suture augment to the double row suture anchor construct would increase the repair's maximum load to failure. A biomechanically stronger repair would potentially decrease the risk of catastrophic failure with early weight-bearing or accidental forced dorsiflexion after operative management for insertional Achilles tendinopathy.

METHODS

Fourteen cadaveric specimens were used to compare the 2 repair techniques. Achilles tendons were debrided and repaired using either a double row suture anchor with and without the additional Krackow rip stop suture augment. The 2 repair techniques were compared using an axial-torsion testing system to measure average load to failure.

RESULTS

The average load to failure for the double row suture anchor repair alone was 152.00 N. The average load to failure for the tendons with the double row suture anchor with the Krackow rip stop augment was 383.08 N. An independent-samples Mann-Whitney U-test was conducted and the suture anchor plus Krackow augment group had a significantly higher load to failure (P = .011, Mann-Whitney U = 5.00, n1 = n2 = 7, P < .05, 2-tailed).

CONCLUSION

This study confirmed that the addition of a Krakow rip stop augment to the double row suture anchor is able to increase the maximum load to failure when compared to the double row suture anchor alone. These results suggest the potential of this added technique to decrease the risk of catastrophic failure.

Insertional Achilles Tendinopathy: Occupational Outcomes in the Military

A retrospective review of consecutive patients diagnosed with insertional Achilles tendinopathy (IAT) was performed. Outcomes included Visual Analog Scale (VAS) pain scores, return to run rates, and return to military duty rates. Our data analysis included 113 patients; 58 (55%) patients required surgery. Mean duration of follow-up was 42 months (range, 12-143). Mean age at the time of surgery was 37.2 years (range, 21-54). VAS scores significantly improved from 5.4 at the preoperative visit to 2.9 at 24 months. There was no significant improvement in VAS scores after the 3-month postoperative visit. Mean return to run time was 9 months (range, 4.5-16). At 1 year, 80% (46/58) of patients returned to military duty. Complications requiring return to the operating room were observed in 6 patients (9%). The high rate of return to duty and significant improvement in pain scores demonstrate that the surgical management of IAT is a viable treatment option for patients who could not otherwise remain on active duty. With that said, the complication rate of 27% is high. Patients and providers should consider the risks, benefits, and duration of therapy during their shared decision-making process.Level of Evidence: Level IV.

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.

12 Cases of Haglund's Syndrome Detected through MRI

BACKGROUND

Haglund's syndrome is a common cause of heel pain but often neglected clinically. Haglund's syndrome refers to a series of symptoms caused by impingement among posterosuperior prominence of the calcaneus, bursa and Achilles tendon. It is difficult to distinguish Haglund's syndrome from other causes of heel pain by clinical diagnosis. Imageology is of great value in the diagnosis of Haglund's syndrome.

OBJECTIVE

Our study aims to summarize the Magnet resonance (MR) imaging characteristics of Haglund's syndrome and provide some reference to clinical work.

METHOD

We retrospectively analyzed the MR images of 11 patients (6 males; 5 females; 6 right ankles, 4 left ankles, 1 bimalleolar ankles) who have been clinically and radiologically confirmed Haglund's syndrome. Observation contents: morphological changes of calcaneus and talus, abnormal signal of calcaneus, abnormal Achilles tendon, and soft tissue abnormalities around Achilles tendon. Combined with literature reviews, summarize the MR imaging features of Haglund's syndrome.

RESULTS

In 12 ankles, all ankles showed posterosuperior prominence of the calcaneus and Achilles tendon degeneration; 7 ankles showed bone marrow edema; 6 Achilles tendons were graded as either type II or type III tendinosis; 5 Achilles tendons showed partial tear; 12 ankles showed retrocalcaneal bursitis, 7 ankles showed retro-Achilles bursitis, 6 ankles showed Kager's fat pad edema.

CONCLUSION

This study found that MR images of Haglund's syndrome showed bone edema of the calcaneus, degeneration and partial tear of the Achilles tendon, the retrocalcaneal and retro-Achilles bursas, and Kager's fat pad edema.

[Treatment of Achilles insertional calcific tendinosis using a longitudinal midline incision approach/central tendon splitting approach]

OBJECTIVE

Treatment of Achilles insertional calcific tendinosis through a longitudinal midline incision approach with optional resection of the retrocalcaneal bursa and calcaneal tuberosity (Haglund's deformity).

INDICATIONS

Calcific Achilles tendinosis, dorsal heel spur, insertional tendinosis.

CONTRAINDICATIONS

General medical contraindications to surgical interventions. Fracture, infection.

SURGICAL TECHNIQUE

Longitudinal skin incision medial of the Achilles tendon. Exposure and midline incision of the Achilles tendon with plantar detachment from the insertion site preserving medial and lateral attachment. Resection of a dorsal heel spur and intratendinous calcifications. Optional resection of the retrocalcaneal bursa and calcaneal tuberosity (Haglund's deformity).

POSTOPERATIVE MANAGEMENT

Partial weight bearing 20 kg in 30° plantar flexion in a long walker boot for 2 weeks. Afterwards 2 weeks of progressively weight bearing in 15° plantar flexion and another 2 weeks in neutral ankle joint position in a long walker boot.

RESULTS

A total of 26 feet of 26 patients with calcific Achilles tendinosis were treated with midline incision of the tendon. In all feet calcific tendon parts were resected. In 10 (38%) feet, a prominent dorsal spur was resected, in 12 feet (38%) retrocalcaneal bursa, and in 24 (92%) feet a calcaneal tuberosity. Mean follow-up was 34.5 months (range 2-64 months). Preoperative Manchester-Oxford Foot Questionnaire (MOXFQ) score was 58.2 (±8.1) and postoperatively the score was 22.75 (±6.0). In all, 7 (26.9%) patients stated delayed wound healing; 1 suffered from deep vein thrombosis. Shoe problems were reported by 50% of patients, and 23.1% suffered from par- or dysesthesia. No revision surgery was required.

Chronic Rupture of Achilles Tendon Caused by Haglund's Deformity: A Case Report

A chronic Achilles tendon rupture is a tendon rupture occurring more than 4-6 weeks after a traumatic injury. Haglund's deformity, caused by bony abnormalities in the ankle (mostly due to osteophyte or bone spur), can cause chronic inflammation and degeneration of the Achilles tendon, eventually leading to rupture. This presents a challenge for clinicians who provide tendon repair procedures. We present a 69-year-old woman who had difficulty moving her left leg and had a deformity on the left leg compared to her right leg after falling nine months before but with pain starting three months before the accident. There was a seven-centimeter gap in the calcaneus with a positive Thompson test. The Haglund's deformity on the left calcaneus was visible on the ankle X-ray. The patient had a chronic total rupture of the left Achilles tendon, which was treated with a flexor hallucis longus (FHL) tendon transfer and resection of the deformity. One week after surgery, the patient's ability to walk and the shape of the left leg improved. This case report describes a chronic left Achilles tendon condition that was successfully repaired through tendon repair surgery using FHL tendon transfer and removal of Haglund's deformity.

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.

Use of Ultrasonically Interdigitated Anchors in Haglund's Deformity Correction Surgery

Haglund's deformity is a common cause of foot pain, with high success rates of surgical intervention. Because early weightbearing rehabilitation correlates with better surgical results, the integrity of anchors employed in these surgeries needs to be evaluated for proper fixation strength, leading to improved postoperative outcomes. The ultrasonically interdigitated anchor is a biodegradable suture anchor that is melted into bony trabeculae using ultrasound, leaving a small biological footprint and less interference on computed tomography and magnetic resonance imaging scans, without loss of fixation strength. We performed a review of 44 patients aged 26 to 84 years treated with either ultrasonically interdigitated anchors or fully threaded titanium anchors during Haglund's deformity excision. Overall, 7 of 14 patients who received an ultrasonically interdigitated anchor reported raw PROMIS (Patient-Reported Outcomes Measurement Information System) scores averaging 14.3, with an average return to ambulation time of 4.2 weeks. Fifteen of 30 patients receiving a fully threaded titanium anchor reported raw PROMIS scores averaging 9.7, with an average return to ambulation time of 3.5 weeks. We found little difference between the outcomes between the 2 anchors and no massive failures or infections in either group, implying that ultrasonically interdigitated anchors are a viable option for Achilles tendon reattachment during Haglund's deformity repair surgery.Levels of Evidence: Level III: Case control study.

MRI in patients with Haglund's deformity and its influence on therapy

INTRODUCTION

Heel pain is one of the common reasons why patients consult orthopaedic surgeons in an outpatient setting. The dorsal heel pain is often caused by a Haglund's deformity which is an exostosis of the posterior superior calcaneus. It often leads to Haglund's syndrome with calcaneal bursitis and Achilles tendinosis. This study aims to investigate the roll of MRI in diagnosis of Haglund's syndrome and its influence on therapy.

MATERIALS AND METHODS

We retrospectively analysed data of 45 patients which clinically and radiologically confirmed Haglund's deformity. Patients were divided into two groups that either did not receive MRI (MRI_0) or received MRI (MRI_1). To evaluate the significance, Fisher´s test was used. A statistical significance was assumed at p < 0.05.

RESULTS

The average age was 57.0 years. There was no significant difference in therapy comparing the groups MRI_0 and MRI_1. Haglund's syndrome was detected in 86.7% of all patients with Haglund's deformity.

CONCLUSION

MRI does not influence the therapy of patients with Haglund's deformity. Therefore, the resources of this cost-intensive and limited type of investigation should be used elsewhere. In cases of atypical heel pain, the MRI might be useful.

Achilles Impingement Tendinopathy on Magnetic Resonance Imaging

Haglund's syndrome is impingement of the retrocalcaneal bursa and Achilles tendon caused by a prominence of the posterosuperior calcaneus. Radiographic measurements are not sensitive or specific for diagnosing Haglund's deformity. Localization of a bone deformity and tendinopathy in the same sagittal section of a magnetic resonance imaging scan can assist with the diagnosis in equivocal cases. The aim of the present cross-sectional study was to determine the prevalence of Haglund's syndrome in patients presenting with Achilles tendinopathy and note any associated findings to determine the criteria for a diagnosis of Haglund's syndrome. We reviewed 40 magnetic resonance imaging scans with Achilles tendinopathy and 19 magnetic resonance imaging scans with Achilles high-grade tears and/or ruptures. Achilles tendinopathy was often in close proximity to the superior aspect of the calcaneal tuberosity, consistent with impingement (67.5%). Patients with Achilles impingement tendinopathy were more often female (p < .04) and were significantly heavier than patients presenting with noninsertional Achilles tendinopathy (p = .014) or Achilles tendon rupture (p = .010). Impingement tendinopathy occurred medially (8 of 20) and centrally (10 of 20) more often than laterally (2 of 20) and was associated with a posterior prominence or hyperconvexity with a loss of calcaneal recess more often than a superior projection (22 of 27 versus 8 of 27; p < .001). Haglund's deformity should be reserved for defining a posterior prominence or hyperconvexity with loss of calcaneal recess because this corresponds with impingement. Achilles impingement tendinopathy might be more appropriate terminology for Haglund's syndrome, because the bone deformity is often subtle. Of the 27 images with Achilles impingement tendinopathy, 10 (37.0%) extended to a location prone to Achilles tendon rupture. Given these findings, insertional and noninsertional Achilles tendinopathy are not mutually exclusive and impingement might be a subtle, unrecognized cause of Achilles tendinopathy and subsequent rupture.

Clinics in diagnostic imaging (170)

A 30-year-old woman presented with a six-month history of left posterior heel pain. Physical examination revealed a tender, inflamed and indurated posterior heel with a visible bony prominence of the posterosuperior aspect of the calcaneus. Lateral ankle radiography showed a prominent left posterosuperior calcaneal tuberosity and thickening of the distal Achilles tendon outline. Magnetic resonance imaging demonstrated high-signal inflammatory fluid in the retrocalcaneal bursa, increased signal intensity and thickening of the Achilles tendon, and prominence of the posterior calcaneus tuberosity with reactive marrow oedema. The findings are consistent with Haglund's deformity. The patient underwent hind foot surgery after failing a six-month course of conservative therapy. There was no further recurrence of symptoms after surgery. The clinical and radiological features of Haglund's deformity are described, including a short discussion of other causes of hind foot pain.

[ENDOSCOPIC CALCANEOPLASTY FOR Haglund's DEFORMITY WITH HINDFOOT PAIN]

OBJECTIVE

To analyze the effectiveness of endoscopic calcaneoplasty (ECP) for treating hindfoot pain in patients with Haglund's deformity by comparing with conservative treatment.

METHODS

According to the included standard, 64 hindfoot pain patients (77 feet) with Haglund's deformity treated between January 2007 and October 2013 were enrolled. Based on the patient's sports habit, 39 patients (49 feet) who had no requirement on sports were given conservative treatment (control group) and 25 patients (28 feet) who had stable sports habit were given ECP (ECP group). There was no significant difference in age, gender, disease duration, disease side, Fowler-Philip angle, and preoperative American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score between 2 groups (P &gt; 0.05).

RESULTS

The patients were followed up 16-44 months (mean, 33.7 months) in ECP group, and 12-40 months (mean, 37.5 months) in control group. In control group, the syndrome in 34 cases (43 feet) disappeared after 2 weeks; pain was improved in 5?cases (6 feet), and pain disappeared at 3 weeks after orthesis immobilization; hindfoot pain recurred in 24 cases (30 feet) during following-up, 11 cases (13 feet) underwent ECP after 1 year. In ECP group, all incisions healed by first intention without nerve injury; no edema or pain was observed during follow-up. AOFAS ankle-hindfoot score was significantly improved in 2 groups when compared with score at pre-treatment (P &lt; 0.05). With time, AOFAS ankle-hindfoot score gradually decreased in control group, but it gradually increased in ECP group. The AOFAS ankle-hindfoot score of ECP group was significantly higher than that of control group after treatment (P &lt; 0.05). According to Ogilvie-Harris score system at 12 months, the results were excellent in 9 cases, good in 12 cases, and poor in 4 cases, with the excellent and good rate of 84.00% in ECP group; and the results were excellent in 8 cases, good in 14 cases, and poor in 17 cases, with the excellent and good rate of 56.41% in control group. There was significant difference in the excellent and good rate between 2 groups (Z=-2.194, P=0.028).

CONCLUSIONS

Under the premise of strict control of surgical indications, the ECP can bring satisfactory effectiveness for treatment of hindfoot pain in patients with Haglund's deformity.

Calcific spurs at the insertion of the Achilles tendon: a clinical and histological study

In active people, insertional calcific tendinopathy (CT) of the Achilles tendon is rare. We evaluated the results of surgical treatment for Achilles tendon CT and analyzed post-surgery Achilles tendon histological features. The study included 36 operations in 34 patients. Twenty-eight (78%) cases had a resection of a Haglund's deformity performed. The mean age of the patients was 42 years (range=23 to 68). Thirteen of the patients were professional athletes and 20 recreational athletes. In twenty-five (69%) cases, the result of surgery was rated good, in nine cases (25%) moderate and in two (6%) cases poor. The mean age of those with a good result was 10 years lower (40 versus 50 years) than those with a moderate result (p=0.0239). Higher athletic activity was also related to a better outcome (p=0.0205). Histology samples showed fast remodellation and stem-cell activation. Surgery seemed to result in a good outcome in patients with or without a Haglund's deformity which failed conservative treatment.