This study evaluated the surgical outcome of treating the Haglund triad, which includes retrocalcaneal exostosis, insertional Achilles tendinosis, and retrocalcaneal bursitis, using a standardized approach of complete detachment and reattachment of the Achilles tendon. Seventeen patients underwent this surgery and reported significant pain reduction, high satisfaction rates, and good functional outcomes post-operatively based on questionnaires and clinical scoring systems. Complications were few and minor in most cases.

1. Surgical Treatment of the Haglund Triad Using Complete Detachment and Reattachment of the Achilles Tendon J. George DeVries, DPM; Ben J. Summerhays, DPM; Daniel W. Guehlstorf, MD Wheaton Franciscan Healthcare – St. Joseph, Milwaukee, WI Purpose: This purpose of this study is to evaluate the outcome of surgical correction of three painful pathologic entities (retrocalcaneal exostosis, insertional Achilles tendinosis, and retrocalcaneal bursitis) performed by one surgeon. The surgical approach was standardized and included complete detachment and reattachment of the Achilles tendon with debridement of bone, tendon and bursa as needed. Methods: This is a retrospective study of the surgical outcome of the Haglund triad after complete detachment/ reattachment of the Achilles tendon, debridement of retrocalcaneal exostosis, and excision of the retrocalcaneal bursa through a medial “J” approach. Patients were sent a questionnaire consisting of visual analog scale, satisfaction survey, and Maryland Foot score. Statistical analysis was performed on pre- and post-operative subjective pain with significance set as a p-value < or = 0.05. Seventeen patients (22 feet) met inclusion criteria which included standardized approach and pre-operative MRI. Results: The average age was 51.6 (+/- 11.6) years with average 40.1 (+/- 27.0) months follow up. There were 12 females and 5 males. Conservative care averaged 20 (+/-21.5) months. The average preoperative VAS score was 7.9 (+/- 2.3) and postoperative VAS was 1.6 (+/- 1.3) with a change of 6.3 and p-value of <0.001. The average post-operative MFS was 91.5 (+/- 9.1) with 16 good to excellent results. Of the 17 patients, 16 (94%) were satisfied and only 1 patient was somewhat unsatisfied. There were 4 complications noted, 3 minor and 1 major. Literature Review: Posterior heel pain is a common complaint presenting to the foot and ankle surgeon. 1 When it entails insertional Achilles tendinosis, retrocalcaneal bursitis, and Haglund’s deformity it is termed in the literature as Haglund’s syndrome or the Haglund triad. 2 Patrick Haglund in 1928 described the deformity. 3 Clinically, there is pain in the posterolateral heel with shoe gear and upon physical exam there is a palpable prominence, erythema, edema, and pain. 4 Conservative therapy has ranged from good to poor results in the literature. In general, non-operative treatment is unsuccessful and surgical treatment is required in about 25% of patients. 5 Diagnosis of the Haglund triad is through clinical exam, and imaging. Plain film radiographic measurements used to determine Haglund’s deformity are controversial and have been shown to not be reliable, and thus were not incorporated in this study. 2 MRI was used in this study as it is uniquely suited to evaluate all three components of the Haglund triad. It has been shown that the presence of partial tearof the Achilles tendon leads to a poor response rate to conservative treatment. 7 Thus several patients had very short courses of conservative care. Loss of muscle strength has been associated with complete detachment and reattachment of the Achilles tendon. Wagner et al analyzed 10 patients treated with a similar approach as utilized in this study, with the addition of a tendon lengthening, and determined that there was a 6% loss of plantarflexion strength in the operated limb. 8 Discussion : The purpose of this study was to evaluate the effectiveness and results of a surgical approach to the Haglund triad. A single surgeon performed a uniform technique to the deformity. This approach was unique in that it did not involve tendon lengthening as has been utilized previously, thus potentially preserving muscle strength. The satis-action of patients whom have had this procedure was recorded. Our results indicate that this is an effective procedure at eliminating pain, resulting in high functional results and patient satisfaction, with relatively few complications. References: 1. DiGiovanni BF, Gould J. Achilles tendonitis and posterior heel disorders. Foot Ankle Clin. 1997 Sept:3(2) 411-28. 2. Sella EJ, Caminear DS, McLarney EA. Haglund's syndrome. J Foot Ankle Surg. 1998 Mar-Apr;37(2):110-4; discussion 173. 3. Haglund P. Bietrag zur klink der achillessehne. Orthop. Chir. 1928:49:49-58. 4. Ruch JA. Haglund's disease. J Am Podiatry Assoc. 1974 Dec;64(12):1000-3. 5. Alfredson H. Lorentzon R. Chronic Achilles tendinosis: recommendations for treatment and prevention. Sports Med. 2000 Feb;29(2):135-46. 6. Fowler A, Philip JF. Abnormality of the calcaneus as a cause of painful heel. Brit J Surg. 1945:32:494-98. 7. Nicholson CW, Berlet GC, Lee TH. Prediction of the success of nonoperative treatment of insertional Achilles tendinosis based on MRI. Foot Ankle Int. 2007 Apr;28(4):472- 8. Wagner E, Gould J, Bilen E, Fleisig GS, Wilk K, Fowler R. Change in plantarflexion strength after complete detachment and reconstruction of the Achilles tendon. Foot Ankle Int. 2004 Nov;25(11):800-4. Chart 1: Subjective Outcome Data Chart 2: Patient Satisfaction Results Table 1: Detailed patient information with associated complications Medial “J” incision T2 Weighted MRI revealing retrocalcaneal exostosis, Achilles tendinosis, and retrocalcaneal bursitis # of total patients enrolled 17 Feet 22 total: 12 right vs. 10 left Age 51.6 (+/- 11.6) years range 24 years to 73 years Sex 12 female vs. 5 males Pre-operative VAS scoring 7.9 (+/- 2.3) range of 2 to 10 Post-operative VAS scoring 1.6 (+/- 1.3) range of 1 to 4.5 Maryland Foot Scoring 91.5 (+/- 9.1) with a range of 65 to 100 Total # of procedures 22 Conservative Therapy Length 20 (+/- 21.5) months (range 1 month to 101 months) Follow-up Length 40.1 (+/- 27.0) months (range 6 months to 105 months) Satisfaction level # of patients selecting Very satisfied 12 Somewhat satisfied 4 No opinion 0 Somewhat unsatisfied 1 Very unsatisfied 0 Age Sex Complication Treatment Course Co-Morbidity 50 M Major : Pulmonary Embolism Hospitalization/Surgery/Anti-coagulation Resolved HTN 39 F Minor : Retrocalcaneal Bursitis Cortisone Injection Resolved None 48 F Minor : Painful scar/Sural Neuritis Neurontin Resolved Mitral Valve Prolapse 40 F Minor : Lymphadema Lymphadema Clinic Long-term Obesity, HTN, GERD