Posterior heel pain is a common presentation in outpatient clinics and there are many different causes [
Actually, Haglund syndrome is an enlargement of the posterosuperior prominence of the calcaneus, which is frequently associated with insertional Achilles tendinitis, bursal projection, and Achilles bursitis [
Haglund syndrome can be treated conservatively or surgically. Conservative treatment included the avoidance of rigid heel counter shoes, use of heel cushions, softer uppers or pads for elevation of the heel, activity modification, or local block treatment. Medication included nonsteroidal anti-inflammatory drugs or corticosteroid injection into retrocalcaneal bursa are also recommended for acute cases. However direct intratendinous steroid injections might weaken the tendon and cause tendon rupture [
Before 2010, a traditional single-row suture method was used to treat Haglund syndrome, by which 50–70% of the Achilles insertion was detached without compromising the tendon. After excision the calcified and the inflamed tendon, a suture anchor was used to reattach and repair the Achilles tendon [
Recently, we treated the Haglund syndrome with the double-row suture technique and obtained good clinical results. In this study, the clinical results, the safety, and efficacy of this procedure were analyzed to evaluate whether this method could give a better long-term result than single-row suture technique.
Thirty-two patients with Haglund syndrome from February 2008 to February 2014 were retrospectively reviewed; all MRI showed the posterosuperior calcaneal prominence or Achilles tendinitis. The detailed information of all 32 patients could refer to Table
The detailed information of the 32 patients.
Group | Gender | Average age | Right or left | Mean follow-up duration | ||
---|---|---|---|---|---|---|
Male | Female | Right | Left | |||
Group 1 | 06 | 10 | 50.6 ± 3 years (range, 21 to 59 years) | 8 (50.0%) | 8 (50.0%) | 3.5 ± 0.8 years (range, 24 to 60 months) |
Group 2 | 05 | 11 | 52.1 ± 2 years (range, 33 to 68 years) | 9 (56.3%) | 7 (43.7%) | 3.5 ± 0.5 years (range, 24 to 60 months) |
Group 1: the patients had traditional single-row suture method.
Group 2: the patients had double-row suture technique.
Patients were selected according to the following criteria: Diagnosed as Haglund syndrome. All treated surgically (either the single-row or double-row suture technique). Follow-up more than 24 months. Having both preoperative and postoperative X-rays and preoperative MRI done.
Exclusion criteria included the following: Old injuries. Patients with any kinds of inflammatory arthritis (such as rheumatoid arthritis). Fracture or other concomitant disorders in the foot and ankle area. Patients who had other comorbidities such as diabetes, severe heart disease, morbid obesity, or peripheral vascular disease who were also excluded to avoid severe surgical complications.
During the surgical procedure, patient was in prone position with a thigh tourniquet. A longitudinal skin incision lateral to Achilles tendon was made. During the surgical procedure, we found most of the patients had degenerative change and inflammation with calcification scattered in their Achilles tendons.
For Group 1, in order to ensure the continuity of Achilles tendon, only 50–70% of the Achilles insertion was detached by sharp-pointed knife. After excision of the bony prominence, the degeneration tissue, scar tissue, calcified and inflammatory tissue in the field of vision, and the detached portion of the Achilles tendon was reattached to the newly created cancellous surface of the calcaneus using one suture anchor. Two sutures connected to the anchor screw were tied with equal tension. The skin was closed with 3-0 nonabsorbable suture. In this operation, the split tendon healed in the form of point-to-point (Figure
(a) 50–70% of the Achilles insertion was detached without compromising the tendon. The calcified lesions were excised. (b) A suture anchor was inserted to reattach and repair of Achilles tendon. (c) The diagram of single-row suture technique.
For Group 2, Achilles insertion was completely detached from the insertion site. After excising the whole bony prominence and the diseased tendon, the first suture anchor was inserted in the proximal calcaneal insertion. Krackow suture technique was used to suture the detached Achilles tendon with the 4 stitches (Knot 1). The next step was to assess the size of the posterosuperior calcaneal prominence and assess whether there was any impingement syndrome by the impaction test. Osteotome was then used to resect the posterosuperior calcaneal prominence. The second suture anchor was inserted in the distal point of calcaneum resection surface (Knot 2). The stitches passed through the terminal part of the Achilles tendon and were tied with the first 4 stitches by the double-row suture technique (Knot 3) (Figure
(a) Achilles tendon insertion was completely detached. The calcified tendon was completely excised. (b) Two suture anchors were inserted to reattach and repair the Achilles tendon. (c) The tendon was repaired with the double-row suture technique. (d) The diagram of double-row suture technique.
All patients were put on a short leg plaster cast with ankle in equinus position for 6 weeks immobilization. They were instructed on non-weight-bearing walking for 6 weeks, before full weight bearing walking was allowed. Passive dorsiflexion and active resistive plantar flexion ankle exercises were started at 6 weeks after surgery. Usually at 3 months’ time, patients could participate in normal daily activities.
The American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scale, the Victorian Institute of Sport Assessment-Achilles (VISA-A) scores, and Arner-Lindholm standard were used to evaluate the surgical outcomes of the patients. The preoperative and postoperative radiological features of calcaneal shapes were also assessed on the standing lateral foot X-ray.
The SPSS software (version 18.0) was used for statistical analyses. The independent sample
All 32 patients in both groups achieved primary healing without anchor loosening, displacement, or rupture of the Achilles tendon. In Group 1, two patients had recurrent symptoms and five patients had mild residual posterior heel pain; those residual symptoms decreased patients’ satisfaction. In Group 2, there were no recurrent cases. 15 patients regained normal range of motion of the ankle joint at 12 weeks and resume low impact sports at 6 mouths without posterior heel pain. One patient had delayed recovery up to one year because of the relative low threshold to pain and inadequate rehabilitation exercise. In Group 2, all patients eventually achieved satisfactory results.
The mean AOFAS ankle-hindfoot scale score, the VISA-A score, and the Arner-Lindholm standard could be refer to in Table
Comparison of functional scores pre- and postoperatively in 2 groups (
Scale | Preoperative score | Latest follow-up score | | |
---|---|---|---|---|
Group 1 | AOFAS ankle-hindfoot scale score | | | 0.0441 |
VISA-A score | | | 0.0408 | |
The Arner-Lindholm standard | 7 excellent, 7 good, 2 bad | |||
Recurrence rate | 2 (12.5%) | |||
Residual heel pain | 5 (31.3%) | |||
| ||||
Group 2 | AOFAS ankle-hindfoot scale score | | | 0.0228 |
VISA-A score | | | 0.0158 | |
The Arner-Lindholm standard | 11 excellent, 5 good, 0 bad | |||
Recurrence rate | 0 | |||
Residual heel pain | 0 |
AOFAS: American Orthopaedic Foot and Ankle Society.
VISA-A: Victorian Institute of Sport Assessment-Achilles.
Data presented as mean ± standard deviation.
Group 1: the patients had traditional single-row suture technique.
Group 2: the patients had double-row suture technique.
Radiologically, there was no posterosuperior bony prominence in the calcaneus in Group 2. And there was no impingement syndrome in all patients. The preoperative and postoperative comparison of the X-ray film could refer be to in Figures
The standing lateral foot X-ray preoperatively (a) and postoperatively (b) showed the calcaneal prominence was excised.
The standing lateral foot X-ray preoperatively and postoperatively showed complete excision of posterosuperior calcaneal prominence. (a) Preoperative X-ray showed obvious posterosuperior calcaneal prominence. (b) Postoperative X-ray showed the location of two suture anchors and the complete excision posterosuperior calcaneal prominence.
Haglund syndrome, firstly described by Swedish orthopedic surgeon Haglund in 1928 [
Patients with Haglund syndrome varies in age from young to elderly, and it is more commonly seen in women [
To date, the management of Haglund syndrome included conservative and surgical treatments [
If conservative treatment failed, surgical intervention should be recommended [
In view of such disease, we conclude that the treatment principles should include excision of the Haglund deformity, relieving the mechanical impingement, and restoring the continuity of Achilles tendon [
In this study, we obtain long-term satisfactory outcomes in an average follow-up period of 3.5 years. Compared to the single-row suture group, all patients obtained primary healing. There are no significant complications, such as spur recurrence or residual heel pain. An analysis of the various ankle-related scores consists of the American Orthopedic Foot and Ankle Society (AOFAS) ankle-hindfoot scale [
Using our technique, we can overcome the previous complications. The complete excision of posterosuperior calcaneal bony prominence (Haglund deformity) can effectively relieve the heel pain and prevent the recurrence. The larger contact surface between tendon and bone will facilitate tendon healing and stability. The shorter period of immobilization (plaster cast after surgery) allowed early functional exercise and reduced the joint stiffness. Early activity also maintains gastrocnemius muscle capacity and minimizes the plantar flexor muscle strength deficit. Therefore, the double-row suture technique can improve clinical outcome of Haglund syndrome.
For those patients with the Haglund syndrome, the double-row suture technique could be a better option for its satisfactory surgical outcomes than traditional single-row suture technique.
The authors declare that there is no conflict of interests regarding the publication of this paper.
Yiqiu Jiang and Yang Li contributed equally to this work.