Histo-Anatomy and Sonographic Examination for the Retrocalcaneal Bursal Complex: EURO-MUSCULUS/USPRM Approach.

Insertional Achilles tendinopathy is an umbrella medical term referring to pain and swelling on the posterior aspect of the calcaneus. High-resolution ultrasound imaging is commonly used in daily practice to assess the pathological changes of the Achilles tendon, cortical bone of the calcaneus, and soft tissues located inside the retrocalcaneal space to optimize the management of relevant patients. To the best of our knowledge, a standardized ultrasound protocol to evaluate the retrocalcaneal bursal complex is lacking in the pertinent literature. In this sense, our step-by-step sonographic approach is intended to be an easy and ready-to-use guide for sonographers/physicians in daily practice to assess this anatomical complex in patients with Achilles tendinopathy. Needless to say, the peculiar histological features of this V-shaped synovial/fibrocartilaginous bursa surrounding the posteroinferior wedge of the Kager's fat pad and the retrocalcaneal space make the examination challenging.

Defining Haglund's deformity radiographically by incorporating the biomechanics of ankle motion.

BACKGROUND: Haglund's deformity is clinically defined by the presence of retrocalcaneal tenderness, with previous radiographic parameters relying on calcaneal anatomic parameters that did not considering the influence of ankle motion on posterior calcaneal-Achilles impingement METHODS: Standing foot radiographs from 55 patients with clinically defined Haglund's deformity were compared to 50 control patients using previously described measurements and 2 new angular measurements based on the linkage between ankle rotation and posterior calcaneal-Achilles impingement. The ability of each measure to distinguish between Haglund's and control patients was assessed. RESULTS: The combination of the angles to account for both increased calcaneal tubercle height and increased posterior calcaneal prominence could distinguish between the two patient groups (p = .018, Area under the curve = 63.2%). None of the previously published radiographic criteria were different between the two patient groups. CONCLUSIONS: The proposed radiographic criteria were more predictive than previous criteria that did not address the role of ankle motion.

Clinical outcomes and complications of the Zadek calcaneal osteotomy in Insertional Achilles Tendinopathy: A systematic review and meta-analysis.

BACKGROUND: The Zadek osteotomy, a dorsal closing wedge osteotomy of the calcaneus, has been described as a treatment option in patients with Insertional Achilles Tendinopathy (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. Functional scores and pain levels were significantly improved after the Zadek osteotomy (p < 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. CONCLUSIONS: The Zadek osteotomy is a safe and effective procedure for patients with IAT. 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. LEVEL OF EVIDENCE: II.

Insertional versus non-insertional tendoachilles tears: a comparative analysis of various predisposing factors and outcome following a repair.

BACKGROUND: Association of tendon degeneration, pre-existing posterior heel pain, Haglund's bump, retrocalcaneal spur, and mode of injury varies for the insertional and non-insertional type of tendoachilles tears (TA). PURPOSE: The study compares the various predisposing factors that determine the distinct type of TA tear and the outcome following a repair. METHODS: This is a retrospective study of the patients who underwent tendoachilles repair during January 2012-June 2018. Patients above 18 years with a minimum follow-up of two years were included. Patients with calcaneal tuberosity avulsions, prior surgeries, and open injuries were excluded. Patients were divided into groups 1 (insertional tears (IT)) and 2 (non-insertional tears (NIT)), and further subdivided based on the tendon degeneration (as D-degenerative and N-normal sub types) from ultrasound findings. AOFAS score and predisposing factors like degeneration, posterior heel pain, Haglund's bump, spur, and mechanism of injury were compared between the groups. RESULTS: The study included N = 146 with a mean age of 51.6 years and mean follow-up of 38.6 (range 24 to 96) months. IT associated with degeneration (IT-D) had a trivial fall as the predominant mechanism (P < 0.001). All patients had significant postoperative improvement of scores with no significant difference between the groups (P = 0.59) and subgroups (P = 0.27).75.34% had degenerative tendon, of which 64.5% were in the IT group and the rest in the NIT group (P = 0.02). 51.4% patients had a Haglund bump in the IT group and n.s. (P = 0.9). Forty-seven percent of patients had pre-existing posterior heel pain, 68% in IT and 32% in NIT (P = 0.04). Subgroup analysis revealed 65% of patients were in the IT-D subgroup (P < 0.001). CONCLUSION: Predisposing factors like posterior heel pain, tendon degeneration, and trivial trauma have a strong propensity for insertional TA tear. In contrast, the prominence of Haglund's bump does not predispose to a distinct type of TA tears. The outcome following a surgical repair-yields good results with no difference between the two groups.

Clinical results of the Keck and Kelly Wedge Osteotomy approach in Haglund's deformity: Minimum 3-year follow-up.

BACKGROUND AND PURPOSE: The Haglund's deformity, which may be difficult to treat non-surgically, is caused by a prominent bone hump in the posterosuperior region of the calcaneus and may be associated with bursitis and foot pain. Many surgical treatments for resistant Haglund deformities have been described. Here, we evaluate the AOFAS scores, pain and other characteristics of patients undergoing removal of the dorsally based wedge from the posterior calcaneus with the Keck and Kelly procedure. MATERIALS AND METHODS: The study included 20 patients who had undergone the Keck and Kelly procedure at our center, from 2011 to 2019, and had attended follow-up for at least three years. Analyses were performed retrospectively. Preoperative (immediately before surgery) and postoperative (at last assessment) American Orthopedic Foot and Ankle Society (AOFAS) and visual analog pain scale scores (VAS) were determined, and calcaneal inclination angles were radiologically measured. Additionally, calcaneal pitch angle (CPA), Fowler and Philip angle (FPA), and Bohler angle were recorded. RESULTS: Fourteen patients were female, and six were male, mean age was 45.8 ± 8.1 years. AOFAS scores were significantly increased, whereas VAS scores were significantly decreased after surgery. Postoperative AOFAS scores were correlated with preoperative VAS, CPA, and FPA values. Preoperative VAS scores were correlated with CPA, FPA, and Bohler angle values. FPA and CPA values were correlated positively. CONCLUSIONS: It was found that ankle functions improved, and pain levels decreased after Keck and Kelly Wedge Osteotomy was applied for the treatment of Haglund's deformity. CPA and FPA were associated with both pain levels and ankle function. The Keck and Kelly Wedge Osteotomy procedure appears to be a preferable approach for the surgical treatment of Haglund's deformity.

Safety and efficacy of image-guided retrocalcaneal bursa corticosteroid injection for the treatment of retrocalcaneal bursitis.

OBJECTIVE: To determine the safety and efficacy of image-guided retrocalcaneal bursa corticosteroid injection for retrocalcaneal bursitis. MATERIALS AND METHODS: After IRB approval, all fluoroscopically guided and ultrasound-guided retrocalcaneal bursa injections (2013-2019) were retrospectively evaluated. Pre-procedure US and radiographs were scored by 2 blinded radiologists in consensus for Achilles tendinosis and retrocalcaneal bursitis (0-3 scale), Achilles enthesopathy (present/absent), and Haglund deformity (present/absent). Pre- and post-procedure pain scores (0-10 scale) evaluated short-term response at 1-4 weeks: excellent (7-10 point decline), good (4-6 point decline), fair (1-3 point decline), or no response. Paired t-test determined significance of short-term improvement. Kaplan-Meier method analyzed time to progression to surgery or complication at 6-month minimum follow-up. Logistic regression analysis evaluated for association between demographic and imaging variables and negative outcome. RESULTS: Two hundred eighteen injections (181 female; mean 54.5 years) performed under ultrasonographic (157, 72%) or fluoroscopic (61, 28%) guidance were evaluated for complication and long-term outcomes. Injections with short-term follow-up (n = 62) yielded excellent or good response in 62.9% (p < 0.00001). Thirty patients (14%) had subsequent elective Achilles surgery. Bursal Doppler flow was associated with progression to surgery (p = 0.00042). No differences were identified in outcomes between US and fluoroscopic-guidance cohorts. Four Achilles ruptures (1.8%) were identified 15-59 days post-injection, each with immediately preceding acute injury. CONCLUSION: Image-guided retrocalcaneal bursa corticosteroid injection yields significant short-term decrease in pain score in majority (63%) of patients. Subsequent Achilles tendon rupture rate was 1.8%. Bursa Doppler flow was significantly correlated with progression to surgery and may represent a negative prognostic indicator.

High patient satisfaction and good long-term functional outcome after endoscopic calcaneoplasty in patients with retrocalcaneal bursitis.

PURPOSE: The primary objective of this study was to determine the degree of patient satisfaction at a minimum of 5 years of follow-up after endoscopic calcaneoplasty. The secondary objectives were to assess functional outcome measures, pain scores, analysis of bone removal, reformation of exostosis at follow-up and correlation of the size of the exostosis and recurrent or persisting complaints. METHODS: This study evaluated patients who underwent endoscopic calcaneoplasty, between January 1st 2000 and December 31st 2010, for the diagnosis of retrocalcaneal bursitis. The evaluation consisted of PROMs (patient-reported outcome measures), a questionnaire and a visit to the outpatient clinic for physical examination and a standard lateral weight-bearing radiograph of the ankle. Patient satisfaction, functional outcomes and pain scores were measured by use of a numeric rating scale (NRS). Size of the posterosuperior calcaneal exostosis was measured on a standard lateral weight-bearing radiograph using parallel pitch lines (PPL) and the Fowler-Philip angle (PFA). RESULTS: The response rate was 28 out of 55 (51%) and the median time to follow-up was 101(IQR 88.5-131.8) months. The median satisfaction score for treatment results was 8.5 out of 10 (IQR 6-10). FAOS symptoms 84.5 (IQR 58.0-96.4), FAOS pain 90.3 (IQR 45.1-100.0), FAOS ADL 94.9 (IQR 58.1-100.0), FAOS sport 90.0 (IQR 36.3-100.0) and FAOS QOL 71.9 (IQR 37.5-93.8) and median AOFAS was 100 (IQR 89-100). The median PLL difference between before operation and 2 weeks after the operation was - 4 mm (IQR-6 and -1) and the median PLL difference between 2 weeks after the operation and at follow-up was 1 mm (0-2). The median PFA was 65 (63-69) at baseline, 66.5 (60.8-70.3) 2 weeks after the operation and 64 (60.8-65.3) at follow-up. CONCLUSION: Despite the limited response rate, this study shows high patient satisfaction and good long-term functional outcome in patients affected by retrocalcaneal bursitis who underwent endoscopic calcaneoplasty. LEVEL OF EVIDENCE: Level IV.

Increasing consensus on terminology of Achilles tendon-related disorders.

PURPOSE: Aims of this study are to evaluate the current terminology and assess the influence of the latest proposals on the terminology used for Achilles tendon-related disorders in both daily practice and literature. METHODS: (1) All orthopedic surgeons experienced in the field of foot and ankle surgery of the Ankleplatform Study Group were invited to participate in this survey by email. They were requested to fill out a survey on terminology in six typical cases with Achilles tendon-related disorders. (2) A systematic literature search of Achilles tendon-related disorders was performed in eight foot and ankle journals in Medline, Embase (Classic) from 2000 to 2016. All extracted terms were counted and compared to the terminology proposals, based on anatomic location, symptoms, clinical findings and histopathology. RESULTS: (1) In total, 141 of the 283 (50%) orthopedic surgeons responded to the survey. In five out of six cases with Achilles tendon-related disorders, the majority gave an answer according to latest proposals. (2) An overview of terminology used for Achilles tendon-related disorders from 2000 to 2016 shows an increase in use of terminology according to the latest proposals based on anatomic location, symptoms, clinical findings and histopathology. CONCLUSION: The revised terminology for Achilles tendon-related disorders based on anatomic location, symptoms, clinical findings and histopathology is used by the majority of orthopedic surgeons and is increasingly used in the literature. However, the indistinct Haglund eponyms are still frequently used in Achilles tendon-related terminology. LEVEL OF EVIDENCE: Level IV.

Endoscopic calcaneoplasty for the treatment of Haglund's deformity provides better clinical functional outcomes, lower complication rate, and shorter recovery time compared to open procedures: a systematic review.

PURPOSE: The aim of this research is to report the clinical outcome following surgical correction of Haglund's deformity summarising different surgical strategies and comparing clinical outcomes, failures, complications and return to activities of patients underwent open and endoscopic techniques. METHODS: A systematic search of the literature was conducted using eight different databases. Thirty-five studies were included in the systematic review. A total of 1260 ankles of 1147 patients were grouped in accordance with the surgical approach (open, endoscopic, or percutaneous). RESULTS: The overall mean age was 44.8 ± 8.2 (range 14.9-82) years with a mean follow-up of 30.9 ± 17.1 (range 3-132) months. Analysis of clinical outcomes of open and endoscopic techniques demonstrated significant differences of AOFAS (87.1 ± 5.9 versus 90.7 ± 4.2 points; P < 0.001), complications (15.5% versus 4.1%; P < 0.001), failures (6.0% versus 1.2%; P < 0.001), time to return to daily activities (17.2 ± 9.3 versus 6.3 ± 1.0 weeks; P < 0.001) and time to return to sport (20.7 ± 3.3 versus 11.9 ± 0.3 weeks; P < 0.001) in the studies that reported these specific outcome measures. CONCLUSION: Surgical correction of Haglund's deformity provides overall good clinical results and high subjective satisfaction. Endoscopic procedures demonstrated better final AOFAS, a lower rate of complications and failures, and shorter recovery time when compared to open techniques. LEVEL OF EVIDENCE: Level IV.

Transtendinous approach calcaneoplasty versus endoscopic calcaneoplasty for Haglund's disease.

PURPOSE: In this study, we performed a comparison between open calcaneoplasty through transtendinous approach and endoscopic calcaneoplasty for Haglund's disease. METHODS: A retrospective review was performed of patients who had undergone either a calcaneoplasty with transtendinous approach or endoscopic for Haglund's disease from three centres. Inclusion criteria were patients with Haglund's disease confirmed radiographically, neutral alignment of the hindfoot and at least one year of follow-up. Patients were excluded in case of ipsilateral ankle osteoarthritis or other neighbouring joints, previous foot surgery, hindfoot malalignment and marked calcific insertional Achilles tendinosis. A chart review was performed to collect demographic data, including age, sex and body mass index (BMI). Functional outcome analysis included the Foot Function Index, AOFAS score and VAS for pain pre-operatively and post-operatively at the last follow-up. This patient-reported outcome scores were used in the native language of each patient (Italian). RESULTS: Clinical and functional outcomes were collected from 54 patients (28 heels treated by open technique and 26 heels treated by endoscopic technique). In the open group, the AOFAS score improved from a pre-operative value of 65.67 ± 10.09 points to a value of 91.78 ± 9.67 points at the last follow-up (P < 0.05). In the endoscopic group, the AOFAS score improved from a pre-operative value of 66.69 ± 7.19 points to a value of 93.69 points ± 10.04 at the last follow-up (P < 0.05). The VAS and the FFI (Disability and Pain) scores were also improved significantly in both groups at the final follow-up evaluation (P < 0.001). Comparing the final follow-up post-operative clinical scores between the two groups, there was no difference in the AOFAS, VAS or the FFI scores between the two groups. No major complications were recorded, except for one Achilles tendon tear after open calcaneoplasty. The satisfaction rate was similar for both techniques. CONCLUSIONS: Both techniques provided good clinical outcomes with a low rate of complications.

The Kager's fat pad radiological anatomy revised.

PURPOSE: The aim of the study was to map connections within the Kager's fat pad between the structures which limit it. METHODS: A retrospective re-review of 200 ankle magnetic resonance imaging (MRI) examination was conducted. Connections within the Kager's fat pad between the superior peroneal retinaculum, the fibulotalocalcaneal ligament, the posterior talocalcaneal ligament, the flexor hallucis longus, the paratenon of the Achilles tendon, the flexor retinaculum and bones were studied and a model of the connections was constructed. RESULTS: The superior peroneal retinaculum was directly connected with the fibulotalocalcaneal ligament in 85.5% of cases, the lateral part of the paratenon in 82.5%, the processus posterior tali in 78.5%, the posterior talofibular ligament in 32%, the flexor retinaculum in 29.5% and the anterior talofibular ligament in 9%. The fibulotalocalcaneal ligament was connected with the paratenon (on the medial side 88.5%, on the lateral side 68.5%), the flexor retinaculum in 70%, the posterior process of the talus in 79%, the osteofibrosus tunnel for the flexor hallucis longus in 53%, the posterior talofibular ligament in 43.5% and the calcaneofibular ligament in 10.5%. The posterior talocalcaneal ligament was connected with the fibulotalocalcaneal ligament in 71%, with the osteofibrosus tunnel for the flexor hallucis longus in 76.5%, with the flexor retinaculum in 70%. The plantaris tendon showed projection to the crural fascia in 34 of % cases. CONCLUSION: In the Kager's fat pad there are present more connections than previously reported. All the connections unit at the level of the posterior process of the talus.

Insertional Achilles Tendinopathy: Analysis of 166 Procedures and Return to Activity.

The surgical procedure for Insertional Achilles tendinopathy (IAT) varies widely with no consensus as to approach and documenting return to activity (RTA). This study presents outcomes of surgery for IAT by a single surgeon, documenting activity level and return to activity. From January 2001 through January 2018, 166 procedures were reviewed. Surgery included debridement of the Achilles insertion, resection of the superior calcaneus and bursa, and re-attachment with suture anchors. There were 110 males and 56 females. The majority of patients in the entire cohort were runners (n = 54). The average age of the cohort was 50.3 ± 12.1 years (range 20-80). Average follow-up was 114.0 ± 63.5 months (range 6-222 months). Average RTA for males and females were 6.43 months and 7.22 months, (p = .2), respectively. There was no difference in RTA between patients who had calcific tendinosis (n = 84) and noncalcific tendinosis (n = 82). Complications were 2 infections, 2 DVTs, and 17 deep suture reactions with a total complication rate of 12.6%; there were no re-ruptures postoperatively. There was no significant difference in number of complications between absorbable and nonabsorbable suture in the anchors (p = .41). The average RM score was 1.5 ± 0.7. The RM scores were better for males (p = .002), but there were no differences in RTA or complications between sexes. Overall, 95.8% of the procedures resulted in improved outcome and ability to return to activity including sports. This retrospective investigation shows surgical intervention for IAT yields good results with an average return to activity including sports in approximately 7 months.

Surgical Takedown Approaches to Insertional Achilles Tendinopathy: A Systematic Review.

Various techniques of surgical detachment for treatment of insertional Achilles tendinopathy have been described, including lateral release, medial release, central tendon splitting (CTS), and complete detachment. A systematic review of electronic databases was performed, encompassing 17 studies involving 703 patients and 746 feet, to compare outcomes associated with surgical takedown techniques. Observed results include wound complication rates (CTS 2.8%; Lateral 0%; Medial 0.4%; Complete 1.3%), postoperative rupture rates (CTS 0.7%; Lateral 0.8%; Medial 0.7%; Complete 2.6%), rate of revision (CTS 0.4%; Lateral 0.9%; Medial 4.2%; Complete 2.6%), rate of infection (CTS 1.1%; Lateral 1.7%; Medial 3.7%; Complete 6.5%). Lateral takedown group was found to have a statistically significant lower rate of complications compared to the complete takedown group (p = .0029). In light of these results, it is recommended that patient characteristics such as case specific tendon pathology and calcaneal morphology take precedent in determining the surgical approach to Achilles takedown.

Achilles tendon-splitting approach and double-row suture anchor repair for Haglund syndrome.

BACKGROUND: Haglund syndrom is characterized as a painful posterosuperior deformity of the heel with possible causes as tight Achilles tendon, high-arched foot and tendency to walk on the outside of the heel. Surgical treatment may be recommended in cases where of insufficient response to nonoperative treatment. This study aims to evaluate the clinical and radiographic results of central Achilles tendon splitting and double-row suture anchor technique in the surgical treatment of patients with Haglund syndrome. METHODS: 27 patients with Haglund syndrome who underwent central Achilles tendon splitting and double-row suture anchor were retrospectively evaluated. The results were evaluated by the pre- and post-operative American Orthopedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale and visual analogue scale (VAS). All patients were evaluated radiographically to assess lateral talus-first metatarsal angle (TMTA), Calcaneal pitch angle (CPA), and the Fowler-Philip angle (FPA) preoperatively and postoperatively. RESULTS: The mean preoperative AOFAS score was 47 ± 7 points; at the end of the follow-up period, it increased to 92 ± 4 points (p < 0.001). The mean preoperative VAS score was 9 ± 0.9 points; at the end of the follow-up period, it was 2 ± 0.6 points (p < 0.001). The lateral TMTA (preoperative: 5° ± 2°; follow-up: 4° ± 2°; p < 0.001), CPA (preoperative: 21° ± 5°; follow-up: 20° ± 5°; p = 0.005) and FPA (preoperative: 55° ± 6°; follow-up: 32° ± 3°; p < 0.001) values decreased at the end of the follow-up period. CONCLUSION: In the absence of an improvement to nonoperative treatment methods, central Achilles tendon-splitting approach appears to be an effective and safe treatment option. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Neglected Iatrogenic Flexor Hallucis Longus Tendon Rupture After Haglund's Endoscopic Surgery: A Case Report.

Rupture of the flexor hallucis longus (FHL) tendon is a rare condition that can occur with direct or indirect trauma; most of the injuries are complete ruptures resulting from laceration. Endoscopic calcaneoplasty is used for treatment of symptomatic Haglund's deformity, and complications of this procedure are rare. Iatrogenic FHL tendon rupture occurring after endoscopic calcaneoplasty has not been reported previously. This case report presents a rare complication after endoscopic calcaneoplasty and the proper method of treatment.

Ultrasound-Guided Minimally Invasive Surgical Resection of Retrocalcaneal Bursitis: A Preliminary Comparison With Traditional Open Surgery.

Posterior heel pain is a common complaint that is often caused by overuse injuries. In such cases, the retrocalcaneal bursa is compressed and chafed repeatedly, leading to local inflammation. Sonography is a popular imaging tool used to study the pathology of soft tissues, and it can be used to assist in diagnosing bursitis because of its accuracy. Herein, we report an innovative method to treat retrocalcaneal bursitis under ultrasound guidance. Ten patients with posterior heel pain for >6 months who failed conservative treatment received this ultrasound-guided minimally invasive surgery. An endoscopic puncher and burr were inserted under ultrasound guidance via a stabbing wound, and the swollen retrocalcaneal bursa and bony prominence were resected. The patients were able to ambulate and undergo a rehabilitation program 2 weeks postoperatively. In the patients who underwent this ultrasound-guided minimally invasive surgery, both the average surgical time and average hospital stay were shorter than in those (n = 12) who underwent open surgery. In outcome rating assessment, the American Orthopaedic Foot & Ankle Society (AOFAS) pain score and total AOFAS ankle-hindfoot score were improved in the ultrasound-guided minimally invasive surgery group compared to the open surgery group at 2 months postoperatively. Other advantages included lesser wound pain, shorter hospital stay, faster recovery time, and minimal blood loss. Accordingly, ultrasound-guided surgery appears to be a good option for the treatment of retrocalcaneal bursitis.

Calcific Insertional Achilles Tendinopathy-Achilles Repair With Flexor Hallucis Longus Tendon Transfer: Case Series and Surgical Technique.

Calcific insertional Achilles tendinopathy (CIAT) is a relatively common musculoskeletal entity that results in significant pain and disability, as well as posterior muscle group weakness. There is a lack of evidence criteria to support the timing of operative intervention, choice of procedures, or whether equinus requires treatment. The purpose of this study was to retrospectively review 45 patients (48 feet) who have undergone surgical management of CIAT with concomitant posterior muscle group weakness with the single heel rise testing. All patients underwent debridement and repair of the Achilles tendon with reattachment of the Achilles tendon to the calcaneus, ostectomy of the calcaneus, and flexor hallucis longus tendon transfer. Those patients with equinus also underwent gastrocnemius recession. The focus includes patient-reported satisfaction, time to return to normal shoe gear, and the incidence of revision surgery. The overall average of time to weightbearing was 4.3 weeks. After surgery, 73.3% (n = 33) of the 45 patients responded to the following question: "Would you have this surgery done again?" Of these patients, 93.9% (n = 31) responded "Yes" and 6.1% (n = 2) responded "Unsure." Of the same 33 patients, 84.8% (n = 28) responded that they were "Very Satisfied" with the procedure and 15.2% (n = 5) responded that they were "Satisfied." Twelve patients (26.7%) did not respond to either question. One of the 12 patients (8.3%) who did not respond had bilateral procedures. None of the patients experienced tendon rupture, deep vein thrombosis, or the need for revision surgery. Four patients (8%) experienced a superficial infection, whereas 1 patient (2%) had development of a deep infection. No correlations were found when looking at the relationship between body mass index and return to weightbearing/normal shoe gear with Spearman analysis.

Cutaneous fibrolipomatous hamartoma: Report of 2 cases with retrocalcaneal location.

Precalcaneal congenital fibrolipomatous hamartoma is an underreported benign entity that has been described in the literature under different names. We present two cases of unilateral fibrolipomatous hamartoma (FLH) appearing in a unique location: on the posterior aspect of the foot overlying the heel. We propose the term "FLH of the skin" as a more inclusive and less confusing term for this condition, thus allowing distinction with FLH arising from neural tissue. High-frequency ultrasonography appears to be a useful diagnostic tool that may avoid unnecessary biopsies for this condition.

Fluoroscopically guided retrocalcaneal bursa steroid injection: description of the technique and pilot study of short-term patient outcomes.

OBJECTIVE: To describe a lateral fluoroscopically guided retrocalcaneal bursa injection technique, report patient outcomes at 1-4 weeks after steroid/anesthetic retrocalcaneal bursal therapeutic injection, and correlate pre-injection diagnostic heel ultrasound variables with improvement in patient pain scores. MATERIALS AND METHODS: After IRB approval, fluoroscopically guided therapeutic retrocalcaneal bursa injections performed using a lateral approach were retrospectively reviewed. Pre-injection heel ultrasound results and pre- and post-injection patient VAS pain scores (scale 0-10) were recorded. The Wilcox matched-pair test compared pain scores, and Spearman's rho assessed for correlation between pain score changes and heel ultrasound results. RESULTS: Thirty-two injections were performed in 30 patients (25 females, 5 males; mean 56.5 ± 9.3 years, range 39-75 years; 21 left heel, 11 right heel) with technical success in 32 of 32 cases (100 %). Insertional Achilles tendon pathology and retrocalcaneal bursitis were present in 31 of 32 cases (97 %) and 16 of 32 cases (50 %), respectively. Median pre- and post-procedure pain scores were 8 (IQR 7, 10) and 1.75 (IQR 0, 6). A statistically significant decrease in pain score was observed following injection, with a median change of 4.75 (IQR 3, 8; p < 0.001). Clinically significant response (>50 % reduction in pain score) was present in 69 % (95 % CI, 0.52-0.86; p < 0.001). No significant correlation was identified between a decrease in pain score and a sonographically abnormal Achilles tendon or retrocalcaneal bursa. CONCLUSION: Fluoroscopically guided retrocalcaneal bursal steroid/anesthetic using a lateral approach is an effective technique. This technique yielded 100 % technical success and a clinically significant decrease in patient pain scores (p < 0.001).

Operative Treatment of Haglund Syndrome With Central Achilles Tendon-Splitting Approach.

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 +5.9° ± 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.