Insertional Achilles Tendinopathy Research Articles

Insertional Achilles tendinopathy: A radiographic cross-sectional comparison between symptomatic and asymptomatic heel of 71 patients

PurposeThis retrospective study aimed to investigate whether the standard radiographic indicators for Haglund's syndrome are applicable to insertional Achilles tendinopathy. MethodsPatients who underwent surgery for insertional Achilles tendinopathy in one heel and experienced no pain in the other heel were enrolled in this study. Preoperative calibrated radiographs of the lateral view of the calcaneus were assessed using (1) calcaneal pitch angle, (2) Fowler-Phillip angle, (3) posterior calcaneal angle, (4) Chauveau-Liet angle, (5) X/Y ratio, (6) Haglund’s deformity height, (7) Haglund’s deformity peak angle, (8) calcification length, (9) calcification width, (10) parallel pitch test, and (11) presence of free body. The Wilcoxon signed rank test and McNemar’s test were used for statistical analyses. ResultsSeventy-one patients (52 males; mean age, 57.2; mean body mass index, 27.1) were included. Mean values for each index in the symptomatic and asymptomatic heels were as follows, respectively: (1) 23.5, 23.0 (p = 0.30); (2) 58.9, 57.8 (p < 0.05); (3) 7.6, 9.2 (p < 0.05); (4) 15.8, 13.9 (p < 0.05); (5) 2.8, 2.8 (p = 0.87); (6) 5.4, 5.0 (p < 0.05); (7) 99.6, 99.0 (p = 0.44); (8) 10.5, 7.6 (p < 0.001); and (9) 5.1, 4.4 (p < 0.05). The sensitivity, specificity, and area under curve of significant indicators were as follows, respectively: (2) 0.78, 0.37, 0.55; (3) 0.45, 0.72, 0.58; (4) 0.63, 0.54, 0.57; (6) 0.45, 0.69, 0.59; (8) 0.48, 0.80, 0.66; and (9) 0.63, 0.54, 0.59. The presence of free body also showed a significant difference between both heels (p < 0.05). ConclusionSome radiographic indicators for Haglund's syndrome are applicable to the diagnosis of insertional Achilles tendinopathy. A comparison of the parameters of Haglund’s syndrome with those of insertional Achilles tendinopathy may illuminate the etiology and pathology of insertional Achilles tendinopathy and lead to novel treatments.

Minimally Invasive Approaches to Haglund's Deformity and Insertional Achilles Tendinopathy: A Contemporary Review.

Minimally Invasive Approaches to Haglund's Deformity and Insertional Achilles Tendinopathy: A Contemporary Review.

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

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. 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. 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. 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.

Outcomes of Percutaneous Zadek Osteotomy for Insertional Achilles Tendinopathy with Two-Year Minimum Follow-Up: A Retrospective Study

Introduction/Purpose: Insertional Achilles tendinopathy (IAT) is a common source of posterior heel pain treated by orthopaedic foot and ankle surgeons. Traditional surgical treatment consists of an open Achilles tendon debridement with re-attachment as well as excision of the posterosuperior calcaneal prominence with or without a gastrocnemius recession. However, frequent complications include wound healing issue, scar pain, weakness and sural nerve injury. Accordingly, the percutaneous ZO is gaining popularity in the field as an alternative to an open midline splitting approach. Limited literature exists describing outcomes of the percutaneous ZO using a larger sample size. The purpose of this study was to analyze patient reported outcomes and complications after percutaneous ZO with a minimum two-year follow-up period. Methods: One hundred and eight cases treated with percutaneous ZO were retrospectively reviewed across October 2017-July 2021 and outcomes data was available for 104 cases with a minimum two-year follow-up. Patient sex, age, and pertinent comorbidities were recorded. Postoperative complications and patient satisfaction following intervention were evaluated. Foot Function Index score (FFI) was utilized to measure patients’ pain and functional outcomes. Visual Analyzing Scale score (VAS) was also utilized to evaluate pain. These measurements were taken at preoperative and final follow-up. Statistical comparisons were performed using two-tailed, paired t-test with p&lt; 0.05. Results: Mean follow-up time was 41.2±13.1 months (range 24-65 months). The mean FFI score improved from 56.1±5.9 (range 47-88) preoperatively to 11.0±5.1 (range 7-59) postoperatively (p &lt; 0.001). Average VAS score improved in patients receiving percutaneous ZO from 7.6±1.3 (range 5-10) to 0.4±0.9 (range 0-7) postoperatively (p &lt; 0.001). The overall complication rate was 3.8% (N =4). Of 104 cases, 98.1% of patients were satisfied with their procedure (102/104). Conclusion: The percutaneous ZO is a safe and highly effective intervention for treatment of IAT. At a minimum of two-years follow-up, this intervention is associated with minimal complications, improved functional outcomes, reduced pain, and high patient satisfaction. Table 1 Functional and subjective pain preoperative and postoperative scores as evaluated by functional foot index (FFI) and visual analogue scale (VAS), respectively

Medial arch instability/internal foot overload association with non-insertional Achilles tendinopathy and the ‘Zone of Conflict Theory’

BackgroundNon insertional Achilles tendinopathy [AT] is a degenerative condition that is prevalent in runners. 30% have no preceding history and many runners do not develop AT. Overuse, pronation, and compromised blood supply are hypothesised as causal. The exact precipitant is still unknown. The link between medial arch instability and AT has not been made. The purpose of this study was to investigate the association between spring ligament (SL) laxity and first ray (FRI) instability, and the presence of (AT). MethodsEthical approval was obtained. Patients were identified from hospital databases for unilateral AT, allowing the opposite unaffected foot to be used as an internal control. SL laxity was measured using the lateral translation score and FRI was measured using a modified digital Klauemeter. Ultrasound was used to assess the tendoachilles [TA] in affected vs unaffected legs. Results17 patients were recruited with a mean age of 55.6 and mean body mass index (BMI) of 33.3. The average symptom duration was 3.62 years. There were 12 left feet and 5 right feet. There was no statistical difference in dorsiflexion angles for the TA or the gastrocnemius. All Beighton scores < 5. Lateral translation scores, FRI scores and TA thickness was significantly greater in AT feet [p < 0.05]. More affected feet had Tibialis posterior tendon pain (TP) [p < 0.05]. ConclusionsFeet with AT exhibit higher lateral translation scores and greater FRI compared to healthy feet, and combined with previous literature evidence, suggests alteration of the subtalar axis alters force moments that may lead to an intrinsic overload of the TA, when the foot enters a "zone of conflict". Medial arch instability, in particular SL laxity and FRI, may contribute to the development of non-insertional AT and treatment of this with early arch support may prevent progressive degeneration.

Haglund resection versus Haglund non-resection for calcific insertional Achilles tendinopathy with Haglund deformity: a retrospective study

BackgroundCalcific insertional Achilles tendinopathy(CIAT) with Haglund deformity is a type of recalcitrant tendinopathy. The necessity of concomitant removal of Haglund deformity during CIAT treatment is controversial. The present study aimed to evaluate the functional outcomes between Haglund resection and Haglund non-resection in the treatment of CIAT with Haglund deformity. MethodsA retrospective study included 29 patients who were underwent Achilles tendon debridement, bursal excision, and subsequent tendon reattachment.for CIAT with Haglund deformity. All patients were divided into 2 groups according to Haglund resection (resection group, n=16) and Haglund non-resection (non-resection group, n=13) using the parallel line method on lateral calcaneal X ray after surgery. Patients were evaluated in terms of the American Orthopedic Foot and Ankle Society (AOFAS), Visual Analog Scale (VAS) and Victorian Institute of Sports Assessment–Achilles (VISA-A) scores and the mean time of activities of daily living (ADL). Anatomy changes included the Fowler-Philip angle, calcaneal pitch angle and Achilles tendon force arm were measured with radiography preoperatively and postoperatively. ResultsBoth groups exhibited a significant increase in AOFAS, VAS and VISA-A scores after surgery. There were no significant differences between the resection group and the non-resection group for the AOFAS (92.38±5.7 vs. 93.15±12.17; P=0.82), VAS (0.5±0.52 vs. 0.61±0.87; P= 0.66) and VISA-A questionnaire (82.56±13.46 vs. 74.92±16.4; P=0.18) at the latest follow-up. The mean time of ADL in the non-resection group was significantly faster compared to that of the resection group (8.15±2.51 weeks vs. 11.31±4.06 weeks, P=0.02). The Fowler-Philip angle of the resection group decreased from 55.55°±12.34° preoperatively to 44.52°±10.24° at the latest follow-up (P=0.001). The Fowler-Philip angle of the non-resection group decreased from 54.38°±8.41° preoperatively to 46.52°±8.02° at the latest follow-up (P=0.016). The calcaneal pitch angle of the resection group increased from 22.76°±5.37° preoperatively to 25.98°±6. 4° at the latest follow-up (P=0.018). The Achilles tendon force arm of the resection group decreased from 178.50mm±5.37mm preoperatively to 173.90mm±8.07mm at the latest follow-up (P=0.018). ConclusionResection or non-resection of the posterosuperior calcaneal tuberosity for CIAT with Haglund deformity would both provide satisfactory functional outcomes. Haglund non-resection may expedite patients' return to their daily activities, suggesting a Haglund deformity resection may be unnecessary in the surgical treatment for CIAT with Haglund deformity.

Immediate and Short-Term Effects of In-Shoe Heel-Lift Orthoses on Clinical and Biomechanical Outcomes in Patients With Insertional Achilles Tendinopathy

Background: Physical therapists frequently employ heel lifts as an intervention to reduce Achilles tendon pain and restore function. Purpose: To determine the short-term effect of heel lifts on clinical and gait outcomes in participants with insertional Achilles tendinopathy (IAT). Study Design: Case series; Level of evidence, 4. Methods: Participants with IAT underwent eligibility screening and completed assessments at baseline and 2 weeks later. Primary outcomes included symptom severity (Victoria Institute of Sports Assessment-Achilles [VISA-A]), gait analysis with the 10-m walk-test at 2 speeds (normal and fast), and pain during walking. Pain and gait analysis were assessed under 3 conditions: before fitting 20-mm heel lifts, immediately after heel-lift fitting, and after 2 weeks of wearing heel lifts. Ultrasound images and measurements at the Achilles insertion were obtained from prone and standing positions (with and without heel lifts). Spatiotemporal gait parameters and tibial tilt angles were evaluated at normal speed using inertia measurement units during the 3 study conditions. Differences between the conditions were analyzed using paired t test or analysis of variance. Results: Overall, 20 participants (12 female, 13 with bilateral IAT; mean age, 51 ± 9.3 years; mean body mass index 31.6 ± 6.8 kg/m2) completed all assessments. Symptom severity (VISA-A) of the more symptomatic side significantly improved at 2 weeks (60 ± 20.6) compared with baseline (52.2 ± 20.4; P &lt; .01). Pain during gait (Numeric Pain Rating Scale) was significantly reduced immediately after heel-lift fitting (0.7 ± 2.0) when compared with baseline (2.2 ± 2.7, P = .043). Spatiotemporal gait parameters and tibial tilt angle before and after using heel lifts at normal walking speed were not significantly different; however, gait speed, stride length, and tibial tilt angle on both sides increased significantly immediately after using heel lifts and were maintained after 2 weeks of wear. Conclusion: Using heel lifts not only improved symptom severity after 2 weeks but also immediately reduced pain during gait and had a positive impact on gait pattern and speed.

A pilot study exploring the use of hyaluronic acid in treating insertional achilles tendinopathy.

This study explores the use of ultrasound-guided Hyaluronic Acid (HA) injections for Insertional Achilles Tendinopathy (IAT). A cohort of 15 ankles diagnosed with IAT received three weekly ultrasound-guided HA injections. The Victorian Institute of Sport Assessment - Achilles (VISA-A) questionnaire scored the severity of symptoms and functional impairment before treatment, and at one and six months post-treatment. Significant improvement was observed in VISA-A scores post-treatment, rising from an average baseline of 34.8 ± 15.2 (11-63) to 53.6 ± 20.9 (15-77) after one month, and then to 50.7 ± 18.6 (20-75) after six months. No adverse reactions were noted, underscoring the safety of the intervention. The pilot study presents HA injections as a potentially effective treatment for IAT, while interpretation of these findings must take into account the variability in results, indicating a range of patient responses. It encourages further research to confirm these findings and to explore HA's full potential in managing IAT, despite the limitations of a small sample size and lack of control group.

Impact of BMI on the Surgical Management of Chronic Insertional Achilles Tendinopathy

Posterior heel pain secondary to insertional Achilles tendinopathy is a common condition that often times requires surgical management. Typically, this involves reflecting a portion of the Achilles tendon from its insertion to adequately debride devitalized or thickened tendon as well as any osseous prominence and then reattached into the calcaneus via suture anchors. Oftentimes, it is suggested that patients with an increased body mass index (BMI) have a higher risk of complications. However, there is no published evidence to support this claim. The present study is a retrospective review of 78 patients who underwent detachment/reattachment of the Achilles tendon for chronic insertional Achilles tendinopathy. Patients were separated into three groups based on BMI: normal, obese, and morbidly obese. The mean BMI of all patients included was 35.6 kg/m2 (range: 21.8-54.9, SD: 6.9). We compared complication rates between the groups and found no significant difference (p = .541). Patients in all groups also demonstrated statistically significant improvements in both American Orthopedic Foot and Ankle Society (AOFAS) hindfoot-ankle scores (Normal BMI: p = .002; Obese: p = <.001; Morbidly obese: p = <.001) and Patient-Recorded Outcomes Measurement Information System (PROMIS) scores (Normal BMI: p = .003; Obese: p = <.001; Morbidly obese: p = .001). In conclusion, the results of our study demonstrate that detachment/reattachment of the Achilles insertion in the management of insertional Achilles tendinopathy in obese and morbidly obese patients may be safe and effective without the risk of increased complications.

Recurrence rates for surgically treated insertional Achilles tendinopathy

IntroductionInsertional Achilles tendinopathy (IAT) is a challenge for every orthopedic surgeon. Although surgical intervention is difficult to avoid after frustrating conservative therapy, little is known about recurrence of this disorder. Therefore the aim of the study was to assess the recurrence rate after primary IAT surgery.Materials and methodsThe authors previous published cohort on primary IAT surgery was reanalyzed. Patients with a follow-up Foot and Function Index (FFI) at one year and final follow-up were included. IAT recurrence was defined as a FFI worsening between one year and final follow-up of > 6.5 points. General demographics, surgical details, complications, and the patient reported outcome (PROM) were assessed.ResultsOut of 58 included patients (51 ± 14 years), 8 patients (14%) suffered IAT recurrence after an average of 50 ± 25 months. None of the assessed factors was predictive for an IAT recurrence.ConclusionIAT recurrence after primary surgery occurs in up to 14% of patients.Level of evidenceIV, retrospective cohort study.

Landmarks for a Minimally Invasive Approach for Haglund's Deformity: A Cadaveric Study.

Haglund's deformity is a posterosuperior calcaneal prominence often associated with a painful bursa and insertional Achilles tendinopathy. Endoscopic debridement has been previously described; however, the aim of this cadaveric study is to describe landmarks of a minimally invasive surgical (MIS) approach to Haglund's deformity. Twelve specimens were dissected to identify medial and lateral portals for minimally invasive burr placement and anchor placement. A standard ruler was used to measure the distance in millimeters from the medial and lateral neurovascular structures in relation to medial and lateral portals. A separate 7-cm longitudinal incision posterior to the lateral malleolus and a separate 7-cm longitudinal incision posterior to the medial malleolus were made to identify at-risk neurovascular structures. The average distance from the sural nerve to the lateral portal was 25.7 mm (23-26). The mean distance from the lateral calcaneal branch of the sural nerve to lateral portal was 11.4 mm (10-12). The mean distance from the tibial nerve to the medial portal was 35.3 mm (35-36). Both the medial and lateral incisions were 9.3 mm from the calcaneal tuberosity. The results indicate that the MIS approach to Haglund's deformity resection can be performed reliably without neurovascular compromise. Level IV.

The compensatory hypertrophy of transferred flexor hallucis longus tendon for insertional Achilles tendinopathy: a retrospective MRI study

Flexor hallucis longus (FHL) transfer is an effective surgery in treating insertional Achilles tendinopathy (IAT). However, limited data exist regarding the post-surgery changes in the transferred FHL. The study aimed to compare the sequential changes and hypertrophy of FHL after isolated FHL transfer (FHLT). We retrospectively enrolled patients who underwent isolated FHLT for insertional Achilles pathology from 2015 to 2020 and divided them into two groups based on whether reattachment of the residue Achilles stump to the FHL was performed or not. We recorded demographic characteristics, MRI parameters, and functional outcome. We also analyzed the correlation between the collected data and FHL hypertrophy. Results revealed no significant differences in most MRI parameters of FHL and functional outcomes between the groups. However, the fat distribution within the FHL showed significant reduction and notable 20.2% hypertrophy after FHLT. Interestingly, the hypertrophy of the FHL was significantly more pronounced in the non-reattached group. Furthermore, we observed a positive correlation between the follow-up period and FHL hypertrophy. In conclusion, the FHL demonstrated significant enlargement over time following FHLT. The compensatory hypertrophy of the transferred FHL was particularly evident and the cumulative incidences of FHL enlargement over time were higher in the non-reattached groupcompared to reattached group. However, both reattachment and non-reattachment of Achilles stump on FHL transfer for insertional Achilles tendinopathy carried similar postoperative functional outcomes.

Flexor Hallucis Longus Transfer And V-Y Plasty: An Effective Treatment Modality for Chronic Achilles Rupture - A Case Series.

To assess outcomes of FHL transfer and V-Y plasty for chronic Achilles rupture due to insertional Achilles tendinopathy. A case series of 12 patients was conducted between 1st January 2017 and 31st December 2018. The patients had short flexor hallucis longus tendon transfer with gastrocnemius lengthening by V-Y plasty for Achilles tendon rupture. Patients were allowed full weight bearing at six weeks post-operatively, and were followed up at three months and six months post-operatively, when the range of motion of the ankle was examined, and the outcome was assessed using the EFAS score. Of the 12 patients in the study, the majority were males; the mean age was 50.6±8.96 years. A significant improvement in dorsiflexion and plantarflexion was noted at the six-month follow-up compared to the three-month follow-up (P=<0.001 for both). When compared to the normal side, dorsiflexion and plantarflexion of the affected ankle were significantly less at three months but were comparable at six months post-operatively. A significant improvement was noted in the mean EFAS score at the six-month follow-up (25.5±5.71) compared to three months (18.6±0.90) post-surgery (P=0.001). Males were also noted to have significantly higher EFAS scores at their six-month follow-up than females (P=0.022). In contrast, a negative correlation was noted between the European Foot and Ankle Society (EFAS) score at the final follow-up and age (P=0.011). FHL tendon transfer with V-Y plasty in chronic Achilles rupture due to insertional Achilles tendinopathy is an effective procedure resulting in the restoration of the ankle range of motion and improvement in functional scores.

The association between refractory plantar fasciitis and insertional Achilles tendinopathy and peripheral spondyloarthritis: a report of human leukocyte antigen B-27 investigation and treatment outcome.

This study aimed to determine the presence of peripheral spondyloarthritis and investigate the clinical characteristics of patients with concurrent peripheral spondyloarthritis in those presenting with refractory plantar fasciitis and Achilles tendinopathy by conducting human leukocyte antigen B-27 (HLA-B27) testing. This retrospective study aimed to investigate patients who complained of persistent pain and significant limitations in daily activities due to their respective foot pain, despite receiving conservative treatment for over one year under the diagnosis of plantar fasciitis or insertional Achilles tendinopathy. The study included 63 patients who underwent HLA-B27 testing. The patients were classified into two groups based on the presence or absence of HLA-B27 positivity. The Mann-Whitney U test assessed significant relationships between continuous variables, and the chi-square test was used to compare categorical variables. Among the 63 included patients, HLA-B27 positivity was confirmed in 11 patients (17.5%), which was significantly associated with a lower average age (22.8years versus 31.7years, P = 0.01) and a substantially lower proportion of females compared to HLA-B27-negative patients (9.1% vs. 25.0%, P = 0.001). Ten of the 11 patients initiated treatment with conventional synthetic disease-modifying antirheumatic drugs (DMARDs) combined with oral steroids as the first-line medication after being diagnosed as HLA-B27 positive. Six patients experienced pain relief with the first-line medication (60%). Four patients who did not achieve pain control with the first-line medication received tumour necrosis factor-alpha inhibitors as the second-line medication. Two patients experienced pain relief, while two experienced reduced but persistent pain. Among the patients with "refractory" plantar fasciitis and insertional Achilles tendinopathy, 17.5% were diagnosed with peripheral spondyloarthritis. Patients diagnosed with peripheral spondyloarthritis had a higher proportion of men and relatively younger mean age compared to those without the diagnosis. Approximately 70% of these patients achieved symptom improvement in foot and ankle joints by taking conventional synthetic DMARDs, TNF-α inhibitors, or both appropriate for spondyloarthritis.

Short-term results of endoscopic calcaneoplasty and retrocalcaneal bursectomy for insertional Achilles tendinopathy.

Although open surgery has traditionally been used as a surgical treatment for insertional Achilles tendinopathy, there is a possibility of serious complications (avulsion, scarring, contracture, sensory changes, and infection) due to the anatomical characteristics of the area. Endoscopic surgery has some advantages due to the smaller incision needed. The purpose of this study was to evaluate the effectiveness of endoscopic surgery in insertional Achilles tendinopathy. Twelve patients (15 feet) who underwent endoscopic surgery between 2015 and 2021 were included in this study. Clinical results were evaluated before and after surgery by visual analog scale (VAS) and, Ogilvie-Harris scores and complications. For radiological evaluation, the Fowler-Philip angle, and positive parallel pitch line were measured. VAS scores decreased from 7.6 preoperatively to 2.3 at the last postoperative follow-up, and Ogilvie-Harris values showed excellent results in 5 cases, good results in 8 cases, and fair results in 2 cases. In the radiographic results, there was no bone prominence above the Pavlov calcaneus pitch line in any case, and the Fowler-Philip angle decreased from an average of 57.5 degrees to 50.2 degrees. Only 1 patient underwent reoperation due to the recurrence of symptoms 33 months after the first surgery. After the second operation, the VAS score decreased to 3 points. No complications occurred. Endoscopic surgery is an effective and minimally invasive procedure, showing fewer complications and similar satisfaction as the open procedure. Therefore, it can be a good treatment option for patients with insertional Achilles tendinopathy as it provides the patient with a quick return to daily life.

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

BackgroundThe 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. MethodsA 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. ResultsSeven 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. ConclusionsClinical 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 evidenceLevel IV; meta-analysis

Therapeutic effects following extracorporeal shock wave therapy for insertional and non-insertional Achilles tendinopathy

BackgroundThe treatment for Achilles tendinopathy varies widely, and there is no consensus regarding the optimal treatment for both non-insertional and insertional Achilles tendinopathy. The purpose of this study was to evaluate the clinical efficacy of extracorporeal shock wave therapy (ESWT) in the treatment of insertional and non-insertional Achilles tendinopathy (AT). MethodsSixty patients with AT were invited to participate in this study. Patients were allocated to one of two groups according to the site of the AT, including an insertional AT (IAT) group and a non-insertional AT (NIAT) group. ESWT was performed once a week for five weeks for both groups. The Victorian Institute of Sport Assessment-Achilles questionnaire (VISA-A) score and the visual analog scale (VAS) were used five times to evaluate the clinical outcomes, including before treatment, immediately after treatment, as well as one month, three months, and five years after treatment. ResultsAt three months after treatment, the IAT group exhibited a significantly higher VISA-A score (82 ± 6 vs. 76 ± 11; p = 0.01) and a significantly lower VAS score (1 ± 1 vs. 2 ± 1; p < 0.001) when compared with the NIAT group. At the five-year assessment, the IAT group (1 ± 1) had a significantly lower VAS score than the NIAT group (2 ± 1) (p = 0.02), while no significant difference for the VISA-A score was observed between the groups (84 ± 8 vs. 84 ± 10; p = 0.98). ConclusionsExtracorporeal shock wave treatment can improve the symptoms of both insertional and non-insertional AT. The IAT patients experienced better clinical outcomes compared with the NIAT patients.

Clinical Outcomes and Complications of the Zadek Calcaneal Osteotomy in Insertional Achilles Tendinopathy: A Systematic Review and Meta-analysis

Category: Hindfoot; Ankle Introduction/Purpose: Insertional Achilles Tendinopathy (IAT) is a degenerative process at the insertion of Achilles tendon onto the calcaneal tuberosity that often coexists with retrocalcaneal bursitis and Haglund’s deformity. The Zadek osteotomy, a dorsal closing wedge osteotomy of the calcaneus, has been described as a treatment option in patients with IAT that have failed conservative management. The aim of this study was to evaluate the clinical outcomes and the complications of the Zadek for the management of IAT. Methods: PubMed, EMBASE and Cochrane Central Register of Controlled Trails (CENTRAL) were searched for all studies to November 2022. PRISMA guidelines were followed. The overall estimates of effect were presented as Weighted Mean Difference (WMD) and 95% confidence intervals (CIs). Meta-analysis was conducted using the Review Manager Software (RevMan, Version 5.4). Results: Ten studies with 232 patients were included. The AOFAS (American Orthopaedic Foot and Ankle Society) Ankle- Hindfoot Score and the VISA-A score (Victorian Institute of Sports of Australia-Achilles score) were significantly improved after the Zadek osteotomy (p &lt; 0.00001). Pain levels were also significantly reduced (p &lt; 0.00001). There were a total of 22 complications reported in the included studies and they were all considered minor. The most common complications were superficial wound infection and sural nerve paraesthesia. Conclusion: The Zadek osteotomy is a safe and effective procedure for patients with IAT. The osteotomy improves pain levels and functions and is associated only with minor complications and a low complication rate. There are no well-designed randomized controlled trials in the literature assessing the outcomes of a Zadek osteotomy against alternate surgical treatments and future research should focus on this.

Semi-Automatic 3D Assessment of Zadek Osteotomy Effects

Category: Hindfoot; Sports Introduction/Purpose: Zadek's procedure is a surgical option to treat insertional Achilles tendinopathy(IAT). This procedure consists of a closing wedge osteotomy of the calcaneus with biomechanical consequences. Great modifications in the hindfoot alignment can result in poor functional outcomes for athletes. Additionally, some authors stated that Zadek osteotomy is a good choice for patients with IAT associated with cavovarus foot. This study aims to analyze the hindfoot alignment and the parameters related to Haglund's syndrome after Zadek's osteotomy using a virtual surgical simulation by specific software. The authors hypothesize that the Zadek is an effective technique to decompress the Achilles tendon against the Haglund deformity without major modifications in the alignment. Methods: A total of 20 WBCT scans of patients with IAT were included. The WBCT images were run through the Foot &amp; Ankle module of Disior's BonelogicTM software, creating a 3D virtual model. With this 3D model built into this software, 20 virtual Zadeck osteotomies standardized with a 10 mm resection wedge were performed using the virtual osteotomy module of Bonelogic®. The Calcaneal Inclination angle (sagittal view)7; Talocalcaneal angle (sagittal view)8; Talocalcaneal angle (axial view)8; Saltzman angle (45 degrees view)9; Saltzman angle (20 degrees view)9; Hindfoot moment arm angle;10 Hindfoot angle10; Fowler Philips angle11 and the calcaneal length7 were measured before and after the virtual osteotomy. These results were compared and statistically analyzed. Results: A virtual Zadek osteotomy was realized in 20 WBCT from patients with an insertional Achilles tendinopathy. Most of the patients were female, and the mean age was 55 years. There were significant statistical differences in the average of the calcaneal length (79 mm to 73 mm), Fowler Philips angle (57º to 43º), calcaneal pitch ( 24º to 20º ), sagittal talocalcaneal angle (55º to 47º ), and the hindfoot moment arm angle (20 º to 21,8º). The axial talocalcaneal angle, Saltzman view 45 º and 20 º, and Hindfoot moment arm showed subtle modifications. Conclusion: The virtual analysis of Zadek's osteotomy decreased the Fowler Philips angle, shortened the calcaneus, and modified the alignment in the sagittal view. It suggests that Zadek's procedure reduces the bone impingement with Achilles and the Achilles push. The effect of this osteotomy in Hindfoot Alignment was subtle, modifying only the sagittal plane.

Achilles tendon disorders: An overview of diagnosis and conservative treatment.

Achilles tendon-related pain affects up to 6% of the US population during their lifetime and is commonly encountered by primary care providers. An accurate diagnosis and early conservative management can improve patient quality of life and reduce unnecessary surgical consultations, saving healthcare dollars. Achilles tendon pathologies can be categorized into acute (pain lasting less than 6 weeks), chronic (pain lasting more than 6 weeks), and acute on chronic (worsening of pain with preexisting chronic Achilles tendon pathology). This article describes the diagnosis, conservative management, indications for imaging, and indications for surgical referral for acute and chronic Achilles tendon rupture, Achilles tendinitis, gastrocnemius strain, plantaris rupture, insertional Achilles tendinopathy, Haglund deformity, and noninsertional Achilles tendinopathy.