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

Abstract

Introduction: Haglund's deformity (a prominence in the posterosuperior aspect of the calcaneum) is a known cause of posterior heel pain. Surgery is reserved for patients after failed conservative treatment. Zadek osteotomy is a dorsal-closing wedge osteotomy that reduces the posterior heel prominence. Zadek osteotomy is becoming a favored procedure, however, there are still relatively few studies focusing on patient-reported outcomes. Our main aim was to assess patient-reported outcomes following the Zadek osteotomy in refractory Haglund's deformity. Our secondary aim was to evaluate the correlation between patient outcomes and changes in their pre and postoperative Fowler-Philip and calcaneal pitch angles.

Methods: We conducted a retrospective review of 19 patients (20 heels) who underwent Zadek osteotomy by a single surgeon at a tertiary hospital over six years. Patient-reported outcomes were collected preoperatively and at 12 months postoperatively using the validated Manchester-Oxford foot questionnaire (MOXFQ) scoring system. We also calculated the difference in their pre and postoperative Fowler-Philip angles and calcaneal pitch using the picture archiving communication system.

Results: There was an average improvement of 108 points in the MOXFQ score at 12 months (P<0.05). There was no statistically significant change in calcaneal pitch. However, the Fowler-Phillip angle dropped with an average of 11.4 º (P<0.05). A decrease in the Fowler-Philip angle does improve patient-related outcome measurement scores, however, the relationship is not directly proportional with "r" measured at 0.23.

Conclusion: Our results show that Zadek osteotomy is a useful procedure to consider in patients with symptomatic refractory Haglund's deformity, with an improvement in patient outcomes at 12 months. However, further studies are needed to give stronger evidence for the efficacy of this procedure and its radiological correlations.

Keywords: calcaneal pitch angle; fowler-philip angle; haglund's deformity; heel prominence; manchester-oxford foot questionnaire; zadek osteotomy.

Figure 1. An extended lateral approach was used to expose the site of the osteotomies. The TA is not visualised or debrided.

TA: Tendo Achilles

Figure 2. Preoperative radiograph of a symptomatic patient with Haglund’s deformity

Figure 3. Postoperative radiograph of the same patient after Zadek osteotomy. The posterior prominence has been reduced, and the prominence has been tilted anteriorly.

Figure 4. The Fowler-Philip Angle

The schematic drawing of the foot illustrating the Fowler-Philip angle is the original work of the first author.

Figure 5. Calcaneal pitch

The schematic drawing of the foot illustrating the calcaneal pitch is an original work of the first author.

Figure 6. Scatter plot showing a decrease in the Fowler-Philip angle and improvement of MOXFQ score postoperatively

MOXFQ: Manchester-Oxford scoring system

Figure 7. The MOXFQ is a patient-reported summary index scoring system widely used for evaluating outcomes in foot and ankle surgery

MOXFQ: Manchester-Oxford foot questionnaire