Zadek osteotomy for the treatment of Haglund’s Syndrome

doi:10.21203/rs.3.rs-39666/v1

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Research article

Zadek osteotomy for the treatment of Haglund’s Syndrome

https://doi.org/10.21203/rs.3.rs-39666/v1

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posted 06 Jul, 2020

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Background: Although several treatment options described in paper, Haglund’s Syndrome (HS) is a challenging common lower extremity disorder. This study reported the clinical outcomes of Zadek osteotomy (ZO) for the treatment of HS.

Methods: This retrospective study included 19 patients who underwent ZO from January 2016 to June 2018. Patients were evaluated using the American Orthopedic Foot Ankle Society ankle-hindfoot scale (AOFAS), Visual Analogue Scale (VAS), ankle range of motion (AROM), and Chauveaux-Liet (CL) angle preoperatively and at final follow-up visit (16.3±4.2) months. Postoperative complications of patients were also recorded.

Results: The ZO exhibited a significant improvement (P＜0.05) in preoperative to postoperative AOFAS (from 53.2±5.4 to 86.4±6.5), VAS ( from 6.3±2.1 to 0.9±1.2 ) scores and CL angle (from 18.2±1.3 to 9.4±2.1 ) degrees, the dorsiflexion of AROM (DAROM) (from 23.4±2.3 to 29.4±1.2) degrees. The planter flexion of AROM (PAROM) (from 32.5±3.5 to 33.2±3.4) degrees (P＞0.05). One postoperative complication was observed: a case of hardware pain in healthy patient. The overall rate of satisfaction after surgery was (94.7%).

Conclusions: ZO is effective and safe procedure for the treatment of HS. This method can be a good option for those patients of HS.

Orthopedics

Zadek’s osteotomy

Haglund’s syndrome

Chauveaux-Liet angle

In 1928, Patrick Haglund described the Haglund deformity firstly^[1]. This deformity refers to an enlargement of the posterolateral heel, which can cause posterior heel pain. This symptom is referred to as Haglund’s syndrome (HS), which includes insertional Achilles tendinopathy (IAT)^{[2, 3]}. The patient with HS often has a red, irritated, painful heel. And they often complain the enlargement of the posterior heel, which make it more difficult to footwear or sport. HS is a common disease. There are many conservative treatment options to treat it, which contains rest, activity modification, ice, or footwear modification^[3]. When these treatment for more than 6 months has failed, surgical options will be considered^[4]. Common surgical methods, including haglund deformity debridement, endoscopic calcaneoplasty, and Zadek osteotomy (ZO)^{[3, 5, 6]}.

In 1939, Zadek described the ZO option for the treatment of HS firstly^[7]. It was later modified by Keck and Kelly in 1965^[8]. ZO is a dorsal closing wedge calcaneal osteotomy that allows the tuberosity of Haglund deformity to be brought forward. This operation can change the calcaneus’ anatomical length and elevate the distal insertion point of the AT^[9]. The aim of this operation as the removal of the underlying bony prominence, which can reduce the impingement between the Achilles tendon (AT) and the posterior calcaneal tuberosity^[10]. Keck and Kelly proved that ZO was an effective treatment for HS^[8]. And Miller reported a good results in 16 patients of HS with that ZO option^[11]. However, Myerson did not agree with osteotomy routinely because of increased morbidity compared with a posterosuperior prominence resection (PPR)^[12]. But some patients still complain some degree of pain after PPR^[13]. Therefore, another operation is required for better outcomes. However, few studies have reported the use of ZO to treat HS, especially in Asia.

This retrospective study aims to evaluate the effectiveness of the ZO for the treatment of HS.

Records of 25 patients with HS who underwent ZO from January 2016 to June 2018 at the Department of Foot and Ankle Surgery, Honghui Hospital, Xi’an Jiaotong University (Xi’an, China) were reviewed. Informed consent was obtained from all study subjects. All procedures were performed by 1 foot and ankle orthopaedic surgeon. A minimum follow-up of 1 year after surgery was required for all patients. Inclusion criteria were patients

Specific inclusion and exclusion criteria were determined for selected patients. Inclusion criteria were patients over 18 years of age, at least 6 months of documented failed conservative treatment, and no prior foot and ankle surgery. Exclusion criteria were patients of HS with AT rupture, diabetes mellitus with or without neuropathic joint destruction, and local infection. Four patients were excluded according to the criteria, and another 2 patients were lost to follow-up. Therefore, 19 cases (19 feet) were included in the current study. The average age at the time of the operation was 48.6 ± 7.3 (range, 31–71) years. The mean follow-up time was 16.3 ± 4.2(range, 13–37) months. Data regarding age, gender, operative side, body mass index (BMI), smoking, and follow-up duration were collected.

Operative Technique

Patients was placed in the lateral position on the operating table. All patients received spinal or epidural anesthesia. A thigh tourniquet with 280 mmHg pressure was applied. Surgical procedures were performed using a full-thickness lateral approach (Fig. 1A). Through a lateral skin incision, the calcaneus was exposed. And then, through the design of pre-operation, closing wedge osteotomy was performed (Fig. 1B). According to the preoperative lateral radiograph of the calcaneus, the design of pre-operation taking into account the angle, width of the wedge, and orientation. When the osteotomy was completed with a shorter blade, the calcaneus was fixed with full threaded cannulated screws under the guidance of 2 K-wires (Fig. 1C). When fixation was finished, using a C-arm device to reconfirm the position of the screws. Then, using a 2 − 0 absorbable suture to repair subcutaneous tissue, and using a 3 − 0 nonabsorbable suture to close the skin.

Postoperative Management

All patients were not allowed to walk for two weeks. All patients were allowed to perform passive motions of the ankle. Skin sutures were removed 2 weeks after surgery. At 8 weeks postoperatively, partial weight bearing was allowed in the removable walker boot. Patients were allowed full weight bearing at 3 months postoperatively.

Clinical And Radiographic Evaluations

Functional evaluations, pain assessments, evaluation of ankle joint, and anatomy changes were collected. Results of the functional evaluations, pain assessments and evaluation of ankle joint performed preoperatively and postoperatively (last follow up visit) were included to determine the Foot Ankle Society ankle-hindfoot scale (AOFAS)^[14], Visual Analogue Scale (VAS)^[15], and ankle range of motion (AROM). Results of anatomy changes included changes in the Chauveaux-Liet (CL) angle^[3](Fig. 2).

Statistical analysis

All data were analyzed statistically using SPSS (version 22.0; IBM, Chicago, IL). Paired t-tests were used to compare the outcomes measures (AOFAS, VAS, ROM and CL angle) recorded before surgery and at last follow-up visit. All values assessed were expressed as the mean ± standard deviation (SD). Statistical significance was defined at P༜0.05.

All patients were followed-up for a minimum of 1 year. No patient presented with infection, nonunion or skin necrosis after the surgery. One patient complained pain on the lateral foot within the first 2 months after the operation, but he had resolution at the 6-month follow-up visit. At the last follow-up, the AOFAS scores increased from 53.2 ± 5.4 (range, 20–57) preoperatively, to 86.4 ± 6.5 (range, 68–100) points postoperatively (P༜0.01). The VAS scores decreased from 6.3 ± 2.1 preoperatively to 0.9 ± 1.2 points postoperatively (P༜0.01). The dorsiflexion of AROM (DAROM) increased from 23.4 ± 2.3 preoperatively to 29.4 ± 1.2 points postoperatively (P༜0.01). The planter flexion of AROM (PAROM) from32.5 ± 3.5 preoperatively to 33.2 ± 3.4 points postoperatively (P༞0.05) (Fig. 3). The CL angle decreased from 18.2 ± 1.3 preoperatively to 9.4 ± 2.1 degrees postoperatively (P༜0.01) (Table 1). The overall rate of satisfaction after surgery was (94.7%).

Table 1

Comparison of clinical indicators between pre- and postoperatively
Scale	AOFAS score	VAS score	DAROM	PAROM	CL angle
Preoperatively	53.2 ± 5.4	6.3 ± 2.1	23.4 ± 2.3	32.5 ± 3.5	18.2 ± 1.3
Postoperatively	86.4 ± 6.5	0.9 ± 1.2	29.4 ± 1.2	33.2 ± 3.4	9.4 ± 2.1
P value	0.000	0.000	0.000	0.536	0.000
Figure

In our study, the AOFAS, VAS, DAROM, and CL angle was significantly improved at the final follow-up (P༜0.01). The ZO showed significant function improvement and pain relief, and no patient were found with infection or nonunion. In another study found that the ZO showed significant pain relief compared to other surgical procedures^[16]. And in study of Maynou^[17], the ZO was also reported has an excellent results.

Haglund deformity is common, which is an abnormality of the posterosuperior part of the calcaneus^[2]. Because the enlargement of the posterolateral heel is near the insertion of the AT, the soft tissue and tendon are compressed during ankle motion^[18]. This symptom is referred to as HS. This impingement of ankle motion is considered the main reason of HS^[19]. Treatment should start off with conservative ways, such as activity modification, ice, or footwear modification. When conservative treatments fail, surgical treatment is required to remove the impingement. However, the posterosuperior prominence resection of tradition cannot solve the impingement between the calcaneus and the insertion of the AT. But the dorsal closing wedge calcaneal osteotomy can remove this impingement. Therefore, the ZO is not only no need for additional resection of the Haglund deformity, but also helpful to relief pain of the impingement.

Previous studies showed the good clinical result with ZO for HS^[17]. But it is not to be noted from 1939 article of Zadek to 1965 study of Keck and Kelly, because of the high rate of postoperative complications^[3]. However, the latest researches show that complications after calcaneal osteotomy is rare, and no significant difference has been found between traditional open operation and minimally invasive approach^{[20, 21]}. In study of Andrea^[22] and Zilu Ge^[10], they found the ZO had a excellent clinical results for HS. And nonunion after ZO was not found for all patients. The mechanism of ZO is likely to elevate the insertion of the AT, and the orientation of the AT was changed. These biomechanical changes can reduce tendon stress and delay the progress of HS and eliminate risk factors^[3]. In our study, the CL angle decreased from 18.2 ± 1.3 preoperatively to 9.4 ± 2.1 degrees postoperatively. The changes of the CL angle could prove it.

In this study, we firstly researched the changes of the AROM preoperatively and postoperatively. The ZO showed significant improved in the AOFAS, VAS, DAROM, and CL angle. However, we found that the PAROM is not significant changed after surgery. The changes of ROM were different. We thought that the main reason has to do with the AT. The AROM is affected by the AT, especially the PAROM. The changes of postoperative DAROM could also prove the advantage of ZO in biomechanical changes. The good clinical results may be attributable to the advantage of ZO.

This study comes with several limitations. This is retrospective design, the small sample size, and the short follow-up. Despite these limitations, and for all we know, this study firstly researched the changes of CL angle and the ROM about ZO. And this study suggests that the ZO is an effective technique for the surgical option of HS.

This study researched the clinical outcomes of ZO for the treatment of HS. The ZO resulted in better functional and biomechanical improvement during short-term follow-up. This method can be a good option for HS.

Haglund’s Syndrome

HS; Zadek osteotomy:ZO; AOFAS:American Orthopedic Foot Ankle Society ankle-hindfoot scale; VAS:Visual Analogue Scale; AROM:ankle range of motion; CL:Chauveaux-Liet;

DAROM

The dorsiflexion of AROM; PAROM:The planter flexion of AROM.

Acknowledgements

Not applicable.

Authors’ contributions

ZWX and DJH designed the study, analysed the data, and wrote the manuscript. LJQ, and ZY collected the data and helped write the manuscript. ZHM and LXJ contributed to research design and revision of the manuscript. All authors read and approved the final manuscript.

Funding

None.

Availability of data and materials

All data and materials regarding the study are available from the corresponding author.

Ethics approval and consent to participate

This study was approved by the Clinical Academic Committee of the Honghui Hospital, Xi’an Jiaotong University and conducted in compliance with the Helsinki Declaration. Written consent was acquired for all patients.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Uncategorized References.
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Version 1

posted 06 Jul, 2020

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Zadek osteotomy for the treatment of Haglund’s Syndrome

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Version 1

Abstract

Figures

Background

Patients And Methods

Operative Technique

Postoperative Management

Clinical And Radiographic Evaluations

Statistical analysis

Results

Discussion

Conclusion

Abbreviations

Declarations

References

Status:

Version 1