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Operative Treatment of Haglund Syndrome With Central Achilles Tendon-Splitting Approach
The Journal of Foot & Ankle Surgery xxx (2015) 1–4
Contents lists available at ScienceDirect
The Journal of Foot & Ankle Surgery journal homepage: www.jfas.org
Original Research
Operative Treatment of Haglund Syndrome With Central Achilles Tendon-Splitting Approach Jae Hoon Ahn, MD 1, Chi-Young Ahn, MD 2, Chu-Hwan Byun, MD 2, Yoon-Chung Kim, MD 3 1
Professor, Department of Orthopaedic Surgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea Orthopedist, Department of Orthopaedic Surgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea 3 Clinical Assistant Professor, Department of Orthopaedic Surgery, St. Vincent’s Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea 2
a r t i c l e i n f o
a b s t r a c t
Level of Clinical Evidence: 4
Haglund syndrome is characterized by chronic posterior heel pain associated with a posterosuperior calcaneal prominence. We assessed the clinical and radiologic outcomes after operative treatment of Haglund syndrome using the central tendon-splitting approach. Fifteen feet in 15 patients were investigated retrospectively after surgery. Of the 15 patients, 14 were males (93.3%) and 1 was female (6.7%). Their mean age was 33.1 8.2 (range 20 to 50) years. The mean follow-up duration was 3.5 1.5 years (range 24 to 90 months). The American Orthopaedic Foot and Ankle Society ankle-hindfoot Scale and Victorian Institute of Sport Assessment-Achilles scores were investigated to assess the clinical outcomes. Patient satisfaction was assessed at the latest follow-up visit. The lateral talo-first metatarsal angle, calcaneal pitch angle, Fowler-Philip angle, and parallel pitch line were measured to assess the foot shape and radiographic outcomes. Clinically, the mean American Orthopaedic Foot and Ankle Society ankle-hindfoot scale score increased from 62.1 7.5 preoperatively to 92.5 3.5 at the latest follow-up visit. The mean Victorian Institute of Sport Assessment-Achilles score increased from 53.2 7.4 to 89.6 3.4. All patients were satisfied with the operative results. Radiographically, all patients had cavus feet with an increased lateral talo-first metatarsal angle (mean þ5.9 5.0 ) and calcaneal pitch angle (mean 26.0 3.8 ). The mean Fowler-Philip angle decreased from 58.9 15.0 to 32.5 7.2 postoperatively, and the positive parallel pitch line had changed to a negative value in all cases. Operative treatment with the central tendon-splitting approach appears to be safe and satisfactory for intractable Haglund syndrome. Ó 2015 by the American College of Foot and Ankle Surgeons. All rights reserved.
Keywords: calcaneus heel insertional Achilles tendinitis parallel pitch lines retrocalcaneal bursitis surgery
Haglund syndrome is one of the causes of chronic posterior heel pain (1) and is characterized by a posterosuperior bony prominence of the calcaneus or Haglund’s deformity (2). It is frequently associated with retrocalcaneal bursitis or insertional Achilles tendinitis (3,4). Haglund’s deformity can cause mechanical impingement of the retrocalcaneal bursa and Achilles tendon. If combined with overuse, it can lead to inflammation and degeneration at the Achilles tendon (5). The initial management of Haglund syndrome is conservative, including shoe wear modification, heel lift, stretching of the gastrocnemius-soleus complex, anti-inflammatory medication, steroid injection, and shockwave therapy (5–7). Operative treatment can be recommended for patients without an adequate response to 3 to 6 months of conservative treatment (7). Operative intervention usually
Financial Disclosure: None reported. Conflict of Interest: None reported. Address correspondence to: Yoon-Chung Kim, MD, Department of Orthopaedic Surgery, St. Vincent’s Hospital, College of Medicine, The Catholic University of Korea, Jungbu-daero 93, Paldal-gu, Suwon-si, Gyeonggi-do, Republic of Korea. E-mail address: [email protected] (Y.-C. Kim).
includes debridement of the diseased tendon, excision of the inflamed bursal tissue, and resection of Haglund’s deformity (8,9). Various operative approaches have been reported, including vertical J-shaped medial (3,10) or lateral (11–13) incision, a double incision (5,14,15), a transverse Cincinnati incision (16), or a central Achilles tendonsplitting incision (15,17–20). However, no consensus has been reached on the ideal operative approach. Although some investigators (18,19) insisted that the central Achilles tendon-splitting approach provides the best exposure to access the insertional Achilles tendinopathy, no comparison study has been performed of the use of the central approach in terms of a functional and radiographic outcomes analysis. We analyzed the clinical and radiographic results of patients with Haglund syndrome who had undergone surgery using the central approach to investigate the safety and efficacy of the procedure and also to evaluate whether any predisposing factors were present in the foot shape to influence the development of the disorder. Patients and Methods The present study included 15 feet in 15 patients who had undergone operative treatment for Haglund syndrome using the central tendon-splitting technique from
1067-2516/$ - see front matter Ó 2015 by the American College of Foot and Ankle Surgeons. All rights reserved. http://dx.doi.org/10.1053/j.jfas.2015.05.002
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J.H. Ahn et al. / The Journal of Foot & Ankle Surgery xxx (2015) 1–4
(FPA) (26), and parallel pitch line (PPL) (27) were measured on the standing foot lateral radiograph (Fig. 1). Patient recruitment, data abstraction, and surgery were performed by the senior author (J.H.A.). The radiographic measurements, statistical analysis, and manuscript preparation were performed by one of us (Y.C.K.). The outcomes assessment was performed by 2 of us (C.Y.A., C.H.B.). Statistical Analysis All data were analyzed statistically using SPSS, version 18.0 (IBM Corp., Armonk, NY). A Wilcoxon signed rank test was used for comparison of the preoperative and postoperative data. Statistical significance was accepted p < .05. Operative Technique
Fig. 1. Radiographic indexes illustrated on a standing lateral foot radiograph. The lateral talo-first metatarsal angle is the angle formed between the long axis of the talus and the first metatarsal (angle between the 2 black lines). The parallel pitch line is defined by 2 parallel lines (2 dotted white lines); the lower line is drawn from the inferior calcaneal tuberosity to the anterior calcaneal tubercle and the upper line from the posterior lip of the talo-calcaneal articular facet in parallel with the lower line. The parallel pitch line is positive if the bursal projection of the tuberosity extends beyond the upper line. a, calcaneal pitch angle, b, Fowler-Philip angle.
August 2001 to April 2010. The study cohort was retrospectively collected. Of the 15 patients, 14 were male (93.3%) and 1 was female (6.7%). Their mean age was 33.1 8.2 (range 20 to 50) years. Of the 15 patients, the right foot was involved in 9 (60.0%) and the left in 6 (40.0%). The mean follow-up duration was 3.5 1.5 years (range 24 to 90 months). The inclusion criteria were Haglund syndrome, surgery with the central approach, and a follow-up duration of >24 months for the outcomes analysis. Patients with any inflammatory arthritis or other combined disorder in the foot and ankle area were excluded to avoid bias in the outcomes analysis. The operation was offered after failure of conservative treatment, such as heel lift, physical therapy, and anti-inflammatory medication for 3 months. All patients demonstrated pain and tenderness on the posterosuperior calcaneal prominence, and had no other comorbidities such as diabetes, severe heart disease, morbid obesity, or peripheral vascular disease. No professional athletes were included in the patient cohort. Clinically, the American Orthopaedic Foot and Ankle Society (AOFAS) anklehindfoot scale (21,22) and the Victorian Institute of Sport Assessment-Achilles (VISAA) (23) scores were assessed to investigate the operative outcomes of the patients. Patient satisfaction was assessed at the latest follow-up visit by asking the patients whether they would elect the surgery again. Radiographically, the lateral talo-first metatarsal angle (TMTA) (24), calcaneal pitch angle (CPA) (25), Fowler-Philip angle
The operative technique involved a central tendon-splitting approach as originally described by McGarvey et al (17). The patient was placed prone on the operating room table, a thigh tourniquet was used, and regional spinal or epidural anesthesia was administered. A midline skin incision was made proximal to the Achilles tendon insertion, extending distally for about 8 cm. Sharp dissection was carried down to the tendon, creating full-thickness skin flaps. The paratenon was centrally incised and tagged with 2-0 VicrylÒ (Ethicon, Johnson & Johnson Medical Ltd., Berkshire, UK) sutures for later repair. Once the Achilles tendon was exposed, it was split centrally to the most inferior attachment of the tendon onto the bone. The tendon was elevated with a knife off the calcaneus bilaterally until the entire distal bony spur was exposed (Fig. 2A). The tendon insertion was not completely detached in all cases. Often, 70% of the tendon detachment was sufficient to visualize the entire distal spur (19). The degenerative portion of the tendon was carefully excised. In all cases, the excised degenerative portion was <50% of the entire tendon. Next, the bony prominence was completely excised using a pneumatic saw or an osteotome in an oblique fashion from distally to proximally (Fig. 2B). After smoothening of the margin with a rasp, the final shape of the calcaneus was confirmed using a fluoroscopic image intensifier. The detached portion of the Achilles tendon was reattached to the newly created cancellous surface of the calcaneus using one 3.5-mm corkscrew suture anchor. Two sutures connected to the anchor screw were tied with equal tension. The split tendon was then repaired with 3-0 absorbable suture using a running stitch (Fig. 2C). The paratenon was also repaired with 3-0 absorbable suture, and the skin was closed with 3-0 nonabsorbable suture. No patient required a flexor hallucis longus tendon transfer or proximal V-Y advancement of the gastrocnemius fascia. Postoperative Management At 2 weeks after surgery, the skin sutures were removed. A postoperative short leg cast was applied with 10 of ankle plantar flexion, and the patient was kept nonweightbearing for the initial 4 weeks. At 4 weeks postoperatively, a short leg cast
Fig. 2. (A) The Achilles tendon was centrally split through the midline skin incision. The exostosis was exposed after splitting of tendon. (B) The exostosis was completely excised in an oblique fashion. (C) The tendon was repaired well with a running stitch after bony excision.
J.H. Ahn et al. / The Journal of Foot & Ankle Surgery xxx (2015) 1–4
Fig. 3. A standing lateral foot radiograph at 2 years postoperatively showing a wellcorrected deformity.
was reapplied with the ankle in neutral dorsiflexion, and weightbearing was allowed. At 6 weeks postoperatively, the patients started range of motion exercises after removal of the cast. Passive dorsiflexion and active resistive plantar flexion ankle exercises were started at this time. At 8 weeks postoperatively, the double heel raise exercise was started. The single heel raise was started at 10 to 12 weeks postoperatively. Usually at 4 months after surgery, the patients could start running again (Fig. 3).
Results The mean AOFAS ankle-hindfoot scale increased from 62.1 7.5 preoperatively to 92.5 3.5 at the latest follow-up visit (p ¼ .001). The mean VISA-A score increased from 53.2 7.4 preoperatively to 89.6 3.4 at the latest follow-up visit (p ¼ .001; Table 1). The mean preoperative lateral TMTA was þ5.9 5.0 . The mean preoperative CPA was 26.0 3.8 . The mean FPA was 58.9 15.0 preoperatively and 32.5 7.2 postoperatively (p ¼ .001; Table 2). The PPL of all patients changed from a positive value preoperatively to a negative value after operative resection of Haglund’s deformity. All 15 patients were satisfied with the operative results and stated they would undergo the operation again if a similar situation should ever occur. No significant complications developed such as the recurrence of the deformity, infection, wound problems, or rupture of the Achilles tendon. Discussion Haglund’s deformity is a posterosuperior calcaneal bony prominence that can lead to intractable chronic heel pain. Since first introduced by Haglund (2), the term for this condition has been confused between Haglund’s deformity and Haglund syndrome. However, it is now accepted that Haglund syndrome is a more comprehensive term because symptoms can develop even without the bony spur present (28). Surgeons have treated symptomatic Haglund syndrome operatively using various approaches. Schepsis and Leach (3) and Schepsis et al (29) used a medial J-shaped incision. Wagner et al (10) also advocated a medial J-shaped incision, stating that the exposure could even reach to the lateral corner of the tendon insertion, an area that Table 1 Comparison of functional scores pre- and postoperatively (N ¼ 15 patients) Scale AOFAS ankle-hindfoot scale VISA-A
Preoperative Score 62.1 7.5 53.2 7.4
Latest Follow-Up Score 92.5 3.5 89.6 3.4
p Value
*
can be incompletely debrided using a medial incision alone. In contrast, Sella et al (28) reported good results after osteotomy and retrocalcaneal bursectomy using a lateral approach. Watson et al (11) preferred the lateral approach because the medial insertion of tendon is more expansive (30); thus, postoperative avulsion is less likely when the lateral Achilles insertion has been elevated. However, a concern always exists regarding iatrogenic sural nerve injury using the lateral approach. Carmont and Maffulli (16) adopted a transverse Cincinnati incision from pediatric clubfoot surgery and insisted that it could allow for adequate exposure and provide cosmetic satisfaction. They reported that the sural nerve split into multiple branches at the transverse incision level and no complication of distal numbness developed. Nevertheless, the concern for iatrogenic nerve injury always remains, because this semi-circumferential incision is almost perpendicular to the course of the sural nerve. In 2002, the central Achilles tendon-splitting approach was first described with good clinical outcomes and high patient satisfaction (17). Johnson et al (18) reported good outcomes with a series of 22 patients who had undergone the surgery using the central approach for insertional Achilles tendinopathy with an average follow-up period of 34 months. Most recently, Nunley et al (19) reported longterm satisfactory outcomes for patients in whom the central approach was used for the treatment of insertional Achilles tendinopathy. The advantage of the central tendon-splitting approach is that it can access all pathologic areas through 1 incision. In contrast, the medial or lateral approach can provide limited exposure, leading to excessive retraction or insufficient debridement. Another advantage of the central approach is that it can avoid the possibility of sural nerve injury that can occur with the lateral (11) and Cincinnati (16) incisions and decrease the insult to the vascular supply to the Achilles tendon. It is known that the vasculature around the Achilles tendon comes through the paratenon and the angiosomes of the Achilles tendon are located medially and laterally (31). Thus, multiple incisions around the hindfoot can sometimes create significant wound problems. Nunley et al (19) reported that the central tendonsplitting approach can minimize the development of wound complications and increase the possibility of good long-term success in terms of tendon strength, range of motion, and function. In the present study, we obtained good outcomes after surgery using the central tendon-splitting approach for intractable Haglund syndrome. All the patients were satisfied with the results after a mean follow-up period of 3.5 1.5 years. No significant complications, such as spur recurrence, wound breakdown, infection, or Achilles tendon rupture, developed. The results of the central tendon-splitting approach have been sparsely reported. Furthermore, most of these studies did not compare the preoperative and postoperative data in terms of functional or radiographic outcomes analysis. Johnson et al (18) only compared the preoperative and postoperative AOFAS scale scores and reported that the score increased significantly after surgery. In contrast, Nunley et al (19) only surveyed the postoperative AOFAS scores. In the present study, the preoperative and postoperative AOFAS scale and VISA-A scores were obtained and compared for evaluation of the functional outcome.
Table 2 Comparison of radiologic indexes pre- and postoperatively (N ¼ 15 patients) Measure
.001 .001
Abbreviations: AOFAS, American Orthopaedic Foot and Ankle Society; VISA-A, Victorian Institute of Sport Assessment-Achilles. Data presented as mean standard deviation. * Wilcoxon signed rank test.
3
Lateral talo-first metatarsal angle ( ) Calcaneal pitch angle ( ) Fowler-Philip angle ( )
Preoperatively
þ5.9 5.0
26.0 3.8 58.9 15.0
Data presented as mean standard deviation. * Wilcoxon signed rank test.
Postoperatively
p Value*
.88
.53 .001
þ6.3 4.7
25.6 3.7 32.5 7.2
4
J.H. Ahn et al. / The Journal of Foot & Ankle Surgery xxx (2015) 1–4
We also performed an analysis of the various radiographic measures such as the lateral TMTA, CPA, FPA, and PPL. The lateral TMTA and CPA are considered indicators of the foot shape (32). The normal range of the lateral TMTA is 4 to þ4 and an angle >þ4 is an indication of a cavus foot (24). The mean lateral TMTA in our study was þ5.9 5.0 , indicating means that the feet of our patients had a high arch. The normal range for the CPA is 10 to 30 (25). The mean CPA in our study was 26.0 3.8 ; a little high but within the normal range. We have supposed that the presence of a high arch might have contributed to the worsening or aggravation of symptoms in the patients with Haglund syndrome, because the posterosuperior prominence of the calcaneus will impinge more on the Achilles tendon as the CPA increases. Therefore, we measured the 2 indexes in the present study, although no previous studies have reported an association of cavus foot with Haglund syndrome. Our results showed that the lateral TMTA and CPA were both high in patients with symptomatic Haglund syndrome. The normal range of the FPA is 44 to 69 (26). The mean preoperative FPA in our study was 58.9 15.0 , also a little high but within the normal range. A high FPA indicates a large posterosuperior prominence of the calcaneus, which can lead to the impingement on the Achilles tendon. The mean FPA decreased to 32.5 7.2 after surgery in our study. Measurement of the PPL was first proposed by Pavlov et al (27). They stated that a positive PPL indicated a posterosuperior prominence of calcaneus and demonstrated that it was associated with patient symptoms. The PPL in our study was positive in all the patients and had changed to a negative value after operative resection. Sella et al (28) proposed that corrective surgery for Haglund syndrome should resect a sufficient amount of the calcaneal spur. In contrast, Kang et al (4) reported that removal of Haglund’s deformity might not be necessary in the operative treatment of insertional Achilles tendinitis. Lu et al (1) also demonstrated that the FPA and PPL would not reflect the severity of symptomatic Haglund syndrome. That is in part because the symptoms of Haglund syndrome in their study were associated with Achilles tendon calcification and a posterior calcaneal spur. Therefore, the surgeon should decide the surgery for symptomatic Haglund syndrome according to the patient’s clinical symptoms. The use of radiographic measurements for the decision to perform surgery should just be ancillary (1). Our study had some limitations. First, it was a retrospective noncomparative cohort study. Second, the number of patients who underwent the procedure was relatively small owing to the strict inclusion criteria. In conclusion, the use of the central tendon-splitting approach appears to be safe and satisfactory for intractable Haglund syndrome. Future comparative studies could be needed to investigate the significance of the association between Haglund syndrome and the cavus foot deformity. References 1. Lu CC, Cheng YM, Fu YC, Tien YC, Chen SK, Huang PJ. Angle analysis of Haglund syndrome and its relationship with osseous variations and Achilles tendon calcification. Foot Ankle Int 28:181–185, 2007. 2. Haglund P. Beitrag zur Klinik der Achillessehne. Z Orthop Chir 49:49–58, 1928.
3. Schepsis AA, Leach RE. Surgical management of Achilles tendinitis. Am J Sports Med 15:308–315, 1987. 4. Kang S, Thordarson DB, Charlton TP. Insertional Achilles tendinitis and Haglund’s deformity. Foot Ankle Int 33:487–491, 2012. 5. Clain MR, Baxter DE. Achilles tendinitis. Foot Ankle 13:482–487, 1992. 6. Paavola M, Kannus P, Jarvinen TA, Khan K, Jozsa L, Jarvinen M. Achilles tendinopathy. J Bone Joint Surg Am 84-A:2062–2076, 2002. 7. Maffulli N, Sharma P, Luscombe KL. Achilles tendinopathy: aetiology and management. J R Soc Med 97:472–476, 2004. 8. Jones D. Retrocalcaneal bursitis and insertional Achilles tendinitis. Sports Med Arthrosc Rev 2:301–309, 1994. 9. Nelen G, Martens M, Burssens A. Surgical treatment of chronic Achilles tendinitis. Am J Sports Med 17:754–759, 1989. 10. Wagner E, Gould JS, Kneidel M, Fleisig GS, Fowler R. Technique and results of Achilles tendon detachment and reconstruction for insertional Achilles tendinosis. Foot Ankle Int 27:677–684, 2006. 11. Watson AD, Anderson RB, Davis WH. Comparison of results of retrocalcaneal decompression for retrocalcaneal bursitis and insertional Achilles tendinosis with calcific spur. Foot Ankle Int 21:638–642, 2000. 12. Yodlowski ML, Scheller AD Jr, Minos L. Surgical treatment of Achilles tendinitis by decompression of the retrocalcaneal bursa and the superior calcaneal tuberosity. Am J Sports Med 30:318–321, 2002. 13. Paavola M, Kannus P, Orava S, Pasanen M, Jarvinen M. Surgical treatment for chronic Achilles tendinopathy: a prospective seven month follow up study. Br J Sports Med 36:178–182, 2002. 14. Kleiger B. The posterior calcaneal tubercle impingement syndrome. Orthop Rev 17:487–493, 1988. 15. Calder JD, Saxby TS. Surgical treatment of insertional Achilles tendinosis. Foot Ankle Int 24:119–121, 2003. 16. Carmont MR, Maffulli N. Management of insertional Achilles tendinopathy through a Cincinnati incision. BMC Musculoskelet Disord 8:82, 2007. 17. McGarvey WC, Palumbo RC, Baxter DE, Leibman BD. Insertional Achilles tendinosis: surgical treatment through a central tendon splitting approach. Foot Ankle Int 23:19–25, 2002. 18. Johnson KW, Zalavras C, Thordarson DB. Surgical management of insertional calcific Achilles tendinosis with a central tendon splitting approach. Foot Ankle Int 27:245–250, 2006. 19. Nunley JA, Ruskin G, Horst F. Long-term clinical outcomes following the central incision technique for insertional Achilles tendinopathy. Foot Ankle Int 32:850– 855, 2011. 20. Downey MS. Essential insights on treating retrocalcaneal exostosis. Podiatry Today 22(11), 2009. Available at: http://www.podiatrytoday.com/essential-insights-ontreating-retrocalcaneal-exostosis. Accessed October 26, 2014. 21. Kitaoka HB, Alexander IJ, Adelaar RS, Nunley JA, Myerson MS, Sanders M. Clinical rating systems for the ankle-hindfoot, midfoot, hallux, and lesser toes. Foot Ankle Int 15:349–353, 1994. 22. Ibrahim T, Beiri A, Azzabi M, Best AJ, Taylor GJ, Menon DK. Reliability and validity of the subjective component of the American Orthopaedic Foot and Ankle Society clinical rating scales. J Foot Ankle Surg 46:65–74, 2007. 23. Robinson JM, Cook JL, Purdam C, Visentini PJ, Ross J, Maffulli N, Taunton JE, Khan KM. The VISA-A questionnaire: a valid and reliable index of the clinical severity of Achilles tendinopathy. Br J Sports Med 35:335–341, 2001. 24. Meary R. On the measurement of the angle between the talus and the first metatarsal. Rev Chir Orthop Reparatrice Appar Mot 53:389, 1967. 25. James ML, John WR, Catherine LH. Imaging of the foot and ankle. In: Mann’s Surgery of the Foot and Ankle, ed. 9, pp. 61–120, edited by MJ Coughlin, CL Saltzman, RB Anderson, Elsevier Saunders, Philadelphia, 2013. 26. Fowler A, Philip JF. Abnormality of the calcaneus as a cause of painful heel: its diagnosis and operative treatment. Br J Surg 32:494–498, 1945. 27. Pavlov H, Heneghan MA, Hersh A, Goldman AB, Vigorita V. The Haglund syndrome: initial and differential diagnosis. Radiology 144:83–88, 1982. 28. Sella EJ, Caminear DS, McLarney EA. Haglund’s syndrome. J Foot Ankle Surg 37:110–114, 1998. 29. Schepsis AA, Wagner C, Leach RE. Surgical management of Achilles tendon overuse injuries: a long-term follow-up study. Am J Sports Med 22:611–619, 1994. 30. Chao W, Deland JT, Bates JE, Kenneally SM. Achilles tendon insertion: an in vitro anatomic study. Foot Ankle Int 18:81–84, 1997. 31. Carr AJ, Norris SH. The blood supply of the calcaneal tendon. J Bone Joint Surg Br 71:100–101, 1989. 32. Rosenbaum AJ, Lisella J, Patel N, Phillips N. The cavus foot. Med Clin North Am 98:301–312, 2014.
Contents lists available at ScienceDirect
The Journal of Foot & Ankle Surgery journal homepage: www.jfas.org
Original Research
Operative Treatment of Haglund Syndrome With Central Achilles Tendon-Splitting Approach Jae Hoon Ahn, MD 1, Chi-Young Ahn, MD 2, Chu-Hwan Byun, MD 2, Yoon-Chung Kim, MD 3 1
Professor, Department of Orthopaedic Surgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea Orthopedist, Department of Orthopaedic Surgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea 3 Clinical Assistant Professor, Department of Orthopaedic Surgery, St. Vincent’s Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea 2
a r t i c l e i n f o
a b s t r a c t
Level of Clinical Evidence: 4
Haglund syndrome is characterized by chronic posterior heel pain associated with a posterosuperior calcaneal prominence. We assessed the clinical and radiologic outcomes after operative treatment of Haglund syndrome using the central tendon-splitting approach. Fifteen feet in 15 patients were investigated retrospectively after surgery. Of the 15 patients, 14 were males (93.3%) and 1 was female (6.7%). Their mean age was 33.1 8.2 (range 20 to 50) years. The mean follow-up duration was 3.5 1.5 years (range 24 to 90 months). The American Orthopaedic Foot and Ankle Society ankle-hindfoot Scale and Victorian Institute of Sport Assessment-Achilles scores were investigated to assess the clinical outcomes. Patient satisfaction was assessed at the latest follow-up visit. The lateral talo-first metatarsal angle, calcaneal pitch angle, Fowler-Philip angle, and parallel pitch line were measured to assess the foot shape and radiographic outcomes. Clinically, the mean American Orthopaedic Foot and Ankle Society ankle-hindfoot scale score increased from 62.1 7.5 preoperatively to 92.5 3.5 at the latest follow-up visit. The mean Victorian Institute of Sport Assessment-Achilles score increased from 53.2 7.4 to 89.6 3.4. All patients were satisfied with the operative results. Radiographically, all patients had cavus feet with an increased lateral talo-first metatarsal angle (mean þ5.9 5.0 ) and calcaneal pitch angle (mean 26.0 3.8 ). The mean Fowler-Philip angle decreased from 58.9 15.0 to 32.5 7.2 postoperatively, and the positive parallel pitch line had changed to a negative value in all cases. Operative treatment with the central tendon-splitting approach appears to be safe and satisfactory for intractable Haglund syndrome. Ó 2015 by the American College of Foot and Ankle Surgeons. All rights reserved.
Keywords: calcaneus heel insertional Achilles tendinitis parallel pitch lines retrocalcaneal bursitis surgery
Haglund syndrome is one of the causes of chronic posterior heel pain (1) and is characterized by a posterosuperior bony prominence of the calcaneus or Haglund’s deformity (2). It is frequently associated with retrocalcaneal bursitis or insertional Achilles tendinitis (3,4). Haglund’s deformity can cause mechanical impingement of the retrocalcaneal bursa and Achilles tendon. If combined with overuse, it can lead to inflammation and degeneration at the Achilles tendon (5). The initial management of Haglund syndrome is conservative, including shoe wear modification, heel lift, stretching of the gastrocnemius-soleus complex, anti-inflammatory medication, steroid injection, and shockwave therapy (5–7). Operative treatment can be recommended for patients without an adequate response to 3 to 6 months of conservative treatment (7). Operative intervention usually
Financial Disclosure: None reported. Conflict of Interest: None reported. Address correspondence to: Yoon-Chung Kim, MD, Department of Orthopaedic Surgery, St. Vincent’s Hospital, College of Medicine, The Catholic University of Korea, Jungbu-daero 93, Paldal-gu, Suwon-si, Gyeonggi-do, Republic of Korea. E-mail address: [email protected] (Y.-C. Kim).
includes debridement of the diseased tendon, excision of the inflamed bursal tissue, and resection of Haglund’s deformity (8,9). Various operative approaches have been reported, including vertical J-shaped medial (3,10) or lateral (11–13) incision, a double incision (5,14,15), a transverse Cincinnati incision (16), or a central Achilles tendonsplitting incision (15,17–20). However, no consensus has been reached on the ideal operative approach. Although some investigators (18,19) insisted that the central Achilles tendon-splitting approach provides the best exposure to access the insertional Achilles tendinopathy, no comparison study has been performed of the use of the central approach in terms of a functional and radiographic outcomes analysis. We analyzed the clinical and radiographic results of patients with Haglund syndrome who had undergone surgery using the central approach to investigate the safety and efficacy of the procedure and also to evaluate whether any predisposing factors were present in the foot shape to influence the development of the disorder. Patients and Methods The present study included 15 feet in 15 patients who had undergone operative treatment for Haglund syndrome using the central tendon-splitting technique from
1067-2516/$ - see front matter Ó 2015 by the American College of Foot and Ankle Surgeons. All rights reserved. http://dx.doi.org/10.1053/j.jfas.2015.05.002
2
J.H. Ahn et al. / The Journal of Foot & Ankle Surgery xxx (2015) 1–4
(FPA) (26), and parallel pitch line (PPL) (27) were measured on the standing foot lateral radiograph (Fig. 1). Patient recruitment, data abstraction, and surgery were performed by the senior author (J.H.A.). The radiographic measurements, statistical analysis, and manuscript preparation were performed by one of us (Y.C.K.). The outcomes assessment was performed by 2 of us (C.Y.A., C.H.B.). Statistical Analysis All data were analyzed statistically using SPSS, version 18.0 (IBM Corp., Armonk, NY). A Wilcoxon signed rank test was used for comparison of the preoperative and postoperative data. Statistical significance was accepted p < .05. Operative Technique
Fig. 1. Radiographic indexes illustrated on a standing lateral foot radiograph. The lateral talo-first metatarsal angle is the angle formed between the long axis of the talus and the first metatarsal (angle between the 2 black lines). The parallel pitch line is defined by 2 parallel lines (2 dotted white lines); the lower line is drawn from the inferior calcaneal tuberosity to the anterior calcaneal tubercle and the upper line from the posterior lip of the talo-calcaneal articular facet in parallel with the lower line. The parallel pitch line is positive if the bursal projection of the tuberosity extends beyond the upper line. a, calcaneal pitch angle, b, Fowler-Philip angle.
August 2001 to April 2010. The study cohort was retrospectively collected. Of the 15 patients, 14 were male (93.3%) and 1 was female (6.7%). Their mean age was 33.1 8.2 (range 20 to 50) years. Of the 15 patients, the right foot was involved in 9 (60.0%) and the left in 6 (40.0%). The mean follow-up duration was 3.5 1.5 years (range 24 to 90 months). The inclusion criteria were Haglund syndrome, surgery with the central approach, and a follow-up duration of >24 months for the outcomes analysis. Patients with any inflammatory arthritis or other combined disorder in the foot and ankle area were excluded to avoid bias in the outcomes analysis. The operation was offered after failure of conservative treatment, such as heel lift, physical therapy, and anti-inflammatory medication for 3 months. All patients demonstrated pain and tenderness on the posterosuperior calcaneal prominence, and had no other comorbidities such as diabetes, severe heart disease, morbid obesity, or peripheral vascular disease. No professional athletes were included in the patient cohort. Clinically, the American Orthopaedic Foot and Ankle Society (AOFAS) anklehindfoot scale (21,22) and the Victorian Institute of Sport Assessment-Achilles (VISAA) (23) scores were assessed to investigate the operative outcomes of the patients. Patient satisfaction was assessed at the latest follow-up visit by asking the patients whether they would elect the surgery again. Radiographically, the lateral talo-first metatarsal angle (TMTA) (24), calcaneal pitch angle (CPA) (25), Fowler-Philip angle
The operative technique involved a central tendon-splitting approach as originally described by McGarvey et al (17). The patient was placed prone on the operating room table, a thigh tourniquet was used, and regional spinal or epidural anesthesia was administered. A midline skin incision was made proximal to the Achilles tendon insertion, extending distally for about 8 cm. Sharp dissection was carried down to the tendon, creating full-thickness skin flaps. The paratenon was centrally incised and tagged with 2-0 VicrylÒ (Ethicon, Johnson & Johnson Medical Ltd., Berkshire, UK) sutures for later repair. Once the Achilles tendon was exposed, it was split centrally to the most inferior attachment of the tendon onto the bone. The tendon was elevated with a knife off the calcaneus bilaterally until the entire distal bony spur was exposed (Fig. 2A). The tendon insertion was not completely detached in all cases. Often, 70% of the tendon detachment was sufficient to visualize the entire distal spur (19). The degenerative portion of the tendon was carefully excised. In all cases, the excised degenerative portion was <50% of the entire tendon. Next, the bony prominence was completely excised using a pneumatic saw or an osteotome in an oblique fashion from distally to proximally (Fig. 2B). After smoothening of the margin with a rasp, the final shape of the calcaneus was confirmed using a fluoroscopic image intensifier. The detached portion of the Achilles tendon was reattached to the newly created cancellous surface of the calcaneus using one 3.5-mm corkscrew suture anchor. Two sutures connected to the anchor screw were tied with equal tension. The split tendon was then repaired with 3-0 absorbable suture using a running stitch (Fig. 2C). The paratenon was also repaired with 3-0 absorbable suture, and the skin was closed with 3-0 nonabsorbable suture. No patient required a flexor hallucis longus tendon transfer or proximal V-Y advancement of the gastrocnemius fascia. Postoperative Management At 2 weeks after surgery, the skin sutures were removed. A postoperative short leg cast was applied with 10 of ankle plantar flexion, and the patient was kept nonweightbearing for the initial 4 weeks. At 4 weeks postoperatively, a short leg cast
Fig. 2. (A) The Achilles tendon was centrally split through the midline skin incision. The exostosis was exposed after splitting of tendon. (B) The exostosis was completely excised in an oblique fashion. (C) The tendon was repaired well with a running stitch after bony excision.
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Fig. 3. A standing lateral foot radiograph at 2 years postoperatively showing a wellcorrected deformity.
was reapplied with the ankle in neutral dorsiflexion, and weightbearing was allowed. At 6 weeks postoperatively, the patients started range of motion exercises after removal of the cast. Passive dorsiflexion and active resistive plantar flexion ankle exercises were started at this time. At 8 weeks postoperatively, the double heel raise exercise was started. The single heel raise was started at 10 to 12 weeks postoperatively. Usually at 4 months after surgery, the patients could start running again (Fig. 3).
Results The mean AOFAS ankle-hindfoot scale increased from 62.1 7.5 preoperatively to 92.5 3.5 at the latest follow-up visit (p ¼ .001). The mean VISA-A score increased from 53.2 7.4 preoperatively to 89.6 3.4 at the latest follow-up visit (p ¼ .001; Table 1). The mean preoperative lateral TMTA was þ5.9 5.0 . The mean preoperative CPA was 26.0 3.8 . The mean FPA was 58.9 15.0 preoperatively and 32.5 7.2 postoperatively (p ¼ .001; Table 2). The PPL of all patients changed from a positive value preoperatively to a negative value after operative resection of Haglund’s deformity. All 15 patients were satisfied with the operative results and stated they would undergo the operation again if a similar situation should ever occur. No significant complications developed such as the recurrence of the deformity, infection, wound problems, or rupture of the Achilles tendon. Discussion Haglund’s deformity is a posterosuperior calcaneal bony prominence that can lead to intractable chronic heel pain. Since first introduced by Haglund (2), the term for this condition has been confused between Haglund’s deformity and Haglund syndrome. However, it is now accepted that Haglund syndrome is a more comprehensive term because symptoms can develop even without the bony spur present (28). Surgeons have treated symptomatic Haglund syndrome operatively using various approaches. Schepsis and Leach (3) and Schepsis et al (29) used a medial J-shaped incision. Wagner et al (10) also advocated a medial J-shaped incision, stating that the exposure could even reach to the lateral corner of the tendon insertion, an area that Table 1 Comparison of functional scores pre- and postoperatively (N ¼ 15 patients) Scale AOFAS ankle-hindfoot scale VISA-A
Preoperative Score 62.1 7.5 53.2 7.4
Latest Follow-Up Score 92.5 3.5 89.6 3.4
p Value
*
can be incompletely debrided using a medial incision alone. In contrast, Sella et al (28) reported good results after osteotomy and retrocalcaneal bursectomy using a lateral approach. Watson et al (11) preferred the lateral approach because the medial insertion of tendon is more expansive (30); thus, postoperative avulsion is less likely when the lateral Achilles insertion has been elevated. However, a concern always exists regarding iatrogenic sural nerve injury using the lateral approach. Carmont and Maffulli (16) adopted a transverse Cincinnati incision from pediatric clubfoot surgery and insisted that it could allow for adequate exposure and provide cosmetic satisfaction. They reported that the sural nerve split into multiple branches at the transverse incision level and no complication of distal numbness developed. Nevertheless, the concern for iatrogenic nerve injury always remains, because this semi-circumferential incision is almost perpendicular to the course of the sural nerve. In 2002, the central Achilles tendon-splitting approach was first described with good clinical outcomes and high patient satisfaction (17). Johnson et al (18) reported good outcomes with a series of 22 patients who had undergone the surgery using the central approach for insertional Achilles tendinopathy with an average follow-up period of 34 months. Most recently, Nunley et al (19) reported longterm satisfactory outcomes for patients in whom the central approach was used for the treatment of insertional Achilles tendinopathy. The advantage of the central tendon-splitting approach is that it can access all pathologic areas through 1 incision. In contrast, the medial or lateral approach can provide limited exposure, leading to excessive retraction or insufficient debridement. Another advantage of the central approach is that it can avoid the possibility of sural nerve injury that can occur with the lateral (11) and Cincinnati (16) incisions and decrease the insult to the vascular supply to the Achilles tendon. It is known that the vasculature around the Achilles tendon comes through the paratenon and the angiosomes of the Achilles tendon are located medially and laterally (31). Thus, multiple incisions around the hindfoot can sometimes create significant wound problems. Nunley et al (19) reported that the central tendonsplitting approach can minimize the development of wound complications and increase the possibility of good long-term success in terms of tendon strength, range of motion, and function. In the present study, we obtained good outcomes after surgery using the central tendon-splitting approach for intractable Haglund syndrome. All the patients were satisfied with the results after a mean follow-up period of 3.5 1.5 years. No significant complications, such as spur recurrence, wound breakdown, infection, or Achilles tendon rupture, developed. The results of the central tendon-splitting approach have been sparsely reported. Furthermore, most of these studies did not compare the preoperative and postoperative data in terms of functional or radiographic outcomes analysis. Johnson et al (18) only compared the preoperative and postoperative AOFAS scale scores and reported that the score increased significantly after surgery. In contrast, Nunley et al (19) only surveyed the postoperative AOFAS scores. In the present study, the preoperative and postoperative AOFAS scale and VISA-A scores were obtained and compared for evaluation of the functional outcome.
Table 2 Comparison of radiologic indexes pre- and postoperatively (N ¼ 15 patients) Measure
.001 .001
Abbreviations: AOFAS, American Orthopaedic Foot and Ankle Society; VISA-A, Victorian Institute of Sport Assessment-Achilles. Data presented as mean standard deviation. * Wilcoxon signed rank test.
3
Lateral talo-first metatarsal angle ( ) Calcaneal pitch angle ( ) Fowler-Philip angle ( )
Preoperatively
þ5.9 5.0
26.0 3.8 58.9 15.0
Data presented as mean standard deviation. * Wilcoxon signed rank test.
Postoperatively
p Value*
.88
.53 .001
þ6.3 4.7
25.6 3.7 32.5 7.2
4
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We also performed an analysis of the various radiographic measures such as the lateral TMTA, CPA, FPA, and PPL. The lateral TMTA and CPA are considered indicators of the foot shape (32). The normal range of the lateral TMTA is 4 to þ4 and an angle >þ4 is an indication of a cavus foot (24). The mean lateral TMTA in our study was þ5.9 5.0 , indicating means that the feet of our patients had a high arch. The normal range for the CPA is 10 to 30 (25). The mean CPA in our study was 26.0 3.8 ; a little high but within the normal range. We have supposed that the presence of a high arch might have contributed to the worsening or aggravation of symptoms in the patients with Haglund syndrome, because the posterosuperior prominence of the calcaneus will impinge more on the Achilles tendon as the CPA increases. Therefore, we measured the 2 indexes in the present study, although no previous studies have reported an association of cavus foot with Haglund syndrome. Our results showed that the lateral TMTA and CPA were both high in patients with symptomatic Haglund syndrome. The normal range of the FPA is 44 to 69 (26). The mean preoperative FPA in our study was 58.9 15.0 , also a little high but within the normal range. A high FPA indicates a large posterosuperior prominence of the calcaneus, which can lead to the impingement on the Achilles tendon. The mean FPA decreased to 32.5 7.2 after surgery in our study. Measurement of the PPL was first proposed by Pavlov et al (27). They stated that a positive PPL indicated a posterosuperior prominence of calcaneus and demonstrated that it was associated with patient symptoms. The PPL in our study was positive in all the patients and had changed to a negative value after operative resection. Sella et al (28) proposed that corrective surgery for Haglund syndrome should resect a sufficient amount of the calcaneal spur. In contrast, Kang et al (4) reported that removal of Haglund’s deformity might not be necessary in the operative treatment of insertional Achilles tendinitis. Lu et al (1) also demonstrated that the FPA and PPL would not reflect the severity of symptomatic Haglund syndrome. That is in part because the symptoms of Haglund syndrome in their study were associated with Achilles tendon calcification and a posterior calcaneal spur. Therefore, the surgeon should decide the surgery for symptomatic Haglund syndrome according to the patient’s clinical symptoms. The use of radiographic measurements for the decision to perform surgery should just be ancillary (1). Our study had some limitations. First, it was a retrospective noncomparative cohort study. Second, the number of patients who underwent the procedure was relatively small owing to the strict inclusion criteria. In conclusion, the use of the central tendon-splitting approach appears to be safe and satisfactory for intractable Haglund syndrome. Future comparative studies could be needed to investigate the significance of the association between Haglund syndrome and the cavus foot deformity. References 1. Lu CC, Cheng YM, Fu YC, Tien YC, Chen SK, Huang PJ. Angle analysis of Haglund syndrome and its relationship with osseous variations and Achilles tendon calcification. Foot Ankle Int 28:181–185, 2007. 2. Haglund P. Beitrag zur Klinik der Achillessehne. Z Orthop Chir 49:49–58, 1928.
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