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

Impact of dorsal closing wedge calcaneal osteotomy on hindfoot alignment and biomechanics of patients with insertional achilles tendinopathy; A weightbearing CT-based simulation study

PURPOSE

Dorsal closing wedge calcaneal osteotomy (DCWCO) is purported to enhance both the biological and mechanical aspects of insertional Achilles tendinopathy (IAT) by altering its insertional anatomy. The biomechanical impacts of shifting the Achilles insertion, however, are not fully understood. This study aimed to analyze the effect of DCWCO on hindfoot alignment and gastrocnemius-soleus (G-S) power.

METHODS

Six weightbearing ankle CTs of patients diagnosed with IAT were segmented and standardized planes were used to conduct DCWCOs with six variations, resulting in a total of 42-foot models including the 6 preoperative original model. Two distinct representations of plantar osteotomy starting points were defined. One was 1 cm anterior to plantar calcaneal tubercle (posterior osteotomy) and the other was 2 cm anterior (anterior osteotomy). The osteotomies were extended to 1 cm anterior of posterosuperior calcaneal tuberosity with 6-, 10-, or 14-mm dorsal wedges. Pre-defined Achilles insertion points were used to create computational Achilles tendon models. Multiple automated measurements were performed to calculate the change in foot alignment and biomechanics.

RESULTS

Both anterior and posterior osteotomy locations resulted in decreased lateral talocalcaneal and calcaneal pitch angles, more substantially so with the anterior osteotomy (p = 0.028). Distance change between Achilles and Haglund was much greater with posterior osteotomy using 6- and 10-mm wedges as compared to the anterior alternative (p = 0.028). Anterior osteotomy caused a significant decrease in the Böhler angle (p < 0.001). The subtalar joint orientation was observed to change up to 3.8° in anterior osteotomy and the decrease in G-S power was found to be a maximum of 2-3 %.

CONCLUSION

A posteriorly placed starting point can provide more Achilles decompression while an anteriorly placed starting point can affect foot alignment more significantly. DCWCO can change the subtalar joint orientation predisposing the joint to increased loads. Decrease in G-S power was low and will presumably not have clinical impact.

Major Heel Reconstructions Through Small Incisions

A variety of osteotomies on the calcaneus have been described in the past to adapt the shape of the calcaneus to specific needs. Newer osteotomy and fixation methods allow the procedure to be as minimally invasive as possible. Recent data suggest that the minimally invasive surgery (MIS) techniques allow for fewer complications, particularly with regard to wound healing. The calcaneus can be cut and shifted in all planes, shortened, and rotated with MIS. Calcaneal MIS has become a major component of foot and ankle surgery.

Severity of Achilles Tendinopathy on Preoperative MRI and Short-term Functional Outcomes After Minimally Invasive Zadek Osteotomy

Background

Limited literature is available to guide surgeons on which patients with insertional Achilles tendinopathy (IAT) may be the best candidates for minimally invasive dorsal closing wedge calcaneal Zadek osteotomy (MIS ZO). We hypothesized that the severity of IAT on preoperative magnetic resonance image (MRI) may correlate with post-operative functional outcomes and help guide patient selection for treatment with MIS ZO.

Methods

Patients who underwent MIS ZO for IAT ± Haglund deformity were identified and retrospectively analyzed. IAT severity was graded on preoperative MRI. Patient Reported Outcome Measurement Information System (PROMIS) scores, complications, and revisions were recorded. Continuous data were compared by analysis of variance with Bonferroni post hoc analysis.

Results

Seventeen patients treated with MIS ZO, with follow-up >6 months, and preoperative MRI met our inclusion criteria. PROMIS pain scores significantly improved in patients with IAT grades 1-3, with 5, 5, and 7 patients, respectively, in each subgroup. In this small series we only identified statistically significant improvements in PROMIS function (P = .031), and mobility (P = .009) scores were only observed in patients with grade 2 pathology. Sixteen of 17 patients (94.2%) were very satisfied with their procedure and would undergo it again.

Conclusion

In this pilot study, we did not find preoperative MRI findings to correlate well with patient-reported outcome scores following MIS ZO.

Level of Evidence

Level IV, case series.

Open Dorsal Closing-Wedge Calcaneal Osteotomy for Haglund Exostosis-Related Heel Pain

BACKGROUND

Dorsal closing-wedge calcaneal osteotomy (DCWCO) is a treatment option for persistent Haglund exostosis-related heel pain after failed conservative management. In modifying the orientation of the calcaneal tendinous insertion site and reducing mechanical stress, the consequences of DCWCO-associated biomechanical changes on everyday foot function remain unknown.

METHODS

This retrospective cohort study analyzed routinely collected clinical data as well as data from our foot and ankle registry. One hundred twenty patients (66 males, 54 females, 17-77 years) who underwent DCWCO from January 2016 to December 2019 were included. Adverse events were collected from the patient files. Foot Function Index (FFI) scores were collected before (baseline) and at 6, 12, and 24 months postsurgery. Radiographic parameters including the Achilles tendon moment arm and X/Y ratio were evaluated from standard preoperative and 6-week postoperative radiographs. Correlations between FFI and biomechanical changes were calculated for men and women separately with the Pearson correlation coefficient and Bonferroni correction.

RESULTS

One intra- and 18 postoperative adverse events were documented. Mean baseline FFI pain decreased from 47.9 ± 17.2 to 12.0 ± 17.5 points at 24 months with an average decrease of -21.8 ± 21.3 points occurring within the first 6 months postsurgery. A similar trend was also seen with the FFI disability score (49.6 ± 20.3 to 12.8 ± 17.6 points). The mean decrease in Achilles tendon moment arm was -8.1 ± 3.8 mm and mean X/Y ratio increased from 2.6 ± 0.3 to 3.8 ± 1.0. There were no significant correlations between the FFI score and radiographic changes.

CONCLUSION

DCWCO effectively alleviates exostosis-related heel pain and associated disabilities. Improvements can still be expected up to 2 years after surgery. Radiographic changes of the foot and ankle are significant but do not correlate with patient-reported outcome measures.

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.

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.

Complications Following Surgical Treatment of Haglund's Syndrome With and Without Flexor Hallucis Longus Tendon Transfer

BACKGROUND

In the surgical treatment of Haglund syndrome, combining a flexor hallucis longus (FHL) tendon transfer with Achilles tendon may improve plantarflexion strength and reduce strain on the repaired Achilles tendon. However, there is limited research comparing complication rates between surgical approaches with or without concurrent FHL tendon transfer.

METHODS

This was retrospective study of patients who underwent surgical management for Haglund syndrome between January 2015 and December 2023. Surgical management included open central-splitting Achilles tendon débridement, Haglund prominence resection, and subsequent Achilles tendon reattachment, either with or without concurrent FHL tendon transfer. Patient demographics, comorbidities, and postoperative complications were collected. Statistical analysis was conducted to compare outcomes between the two groups.

RESULTS

Among the 390 patients who underwent surgical intervention for Haglund syndrome, 52 individuals received FHL tendon transfer. The average follow-up duration was 10.1 ± 12.9 months. Overall, complications included persistent pain (10.3%), wound breakdown (8.2%), infection (1.8%), plantar flexion weakness (1.5%), and Achilles tendon rupture (0.3%). No notable difference was observed in complication rates between the two groups. However, wound breakdown was higher in the FHL tendon transfer group compared with the non-FHL group (P = 0.5). No patients who received a FHL tendon transfer experienced a postoperative Achilles tendon rupture.

CONCLUSION

In the largest study of patients who underwent surgical treatment for Haglund syndrome, with or without FHL tendon transfer, the overall complication rate was comparable. However, the FHL tendon transfer group exhibited a higher tendency for wound breakdown.

Comparison of open and endoscopic techniques of isolated calcaneoplasty in the surgical treatment of insertional tendinopathy of the Achilles tendon

INTRODUCTION

Insertional Achilles tendinopathy (IAT) is primarily caused by mechanical overload. Running and obesity are major risk factors. Medical treatment is limited, and surgery, particularly calcaneoplasty, is sometimes necessary. However, the choice between an endoscopic and open approach remains controversial.

HYPOTHESIS

This study is based on the hypothesis that endoscopic surgery would allow for better functional recovery with a faster return to sports activity compared to traditional open techniques.

MATERIALS AND METHODS

Our multicenter prospective study compared the outcomes of endoscopic (Endo) and open (Open) calcaneoplasty in patients with IAT resistant to medical treatment. Clinical outcomes were assessed using the EFAS (daily life and sports) and VISA-AF scores. The radiological criteria studied were the calcaneal slope and the X/Y ratio. An MRI was used to quantify tendon involvement.

RESULTS

Of the 85 patients included, 51 underwent endoscopic surgery, and 34 had open surgery. The two groups were comparable in terms of demographic, clinical, and radiographic characteristics. At 3 months postoperatively, significantly more patients had returned to sports in the Endo group (41.6% vs. 20.6% in the Open group; p = 0.004), and the EFAS sports score showed a significant difference in favor of the Endo group at 6 months postoperatively (9.3 vs. 5.7/16; p = 0.008).

DISCUSSION

The results confirm faster recovery after endoscopic surgery, with comparable complication rates between the two approaches. However, long-term, the differences between the two techniques diminish, with similar functional outcomes at 12 months postoperatively.

CONCLUSION

Endoscopic calcaneoplasty is a safe and effective option for the treatment of IAT. However, further studies with longer follow-up are needed to confirm these results and assess recurrence rates.

LEVEL OF EVIDENCE

III.

Outcomes After Percutaneous Zadek Osteotomy for Insertional Achilles Tendinopathy

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.

Dorsal calcaneal wedge removal in zadek osteotomy: A cadaveric study

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.

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.

The Heel Complex: Anatomy, Imaging, Pathologic Conditions, and Treatment

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.

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.

Comparison between achilles tendon reinsertion and dorsal closing wedge calcaneal osteotomy for the treatment of insertional achilles tendinopathy: A meta-analysis

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.

Effect of sequential burr passes on osteotomy magnitude and calcaneal morphology in minimally invasive Zadek osteotomy

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.

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.

Zadek Osteotomy, a Good Treatment Option for Refractory Haglund's Deformity

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.

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.

Calcaneal osteotomy due to insertional calcaneal tendinopathy: preoperative planning

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.

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.

Surgical Treatment of Haglund’s Deformity: A Systematic Review and Meta-Analysis

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.