Restricted accessResearch articleFirst published online 2026
Comparison of Dorsal Closing Wedge Calcaneal Osteotomy and Exostectomy With Tendon Repair for Insertional Achilles Tendinopathy in Mild-to-Moderate Cases
Background. The optimal surgical approach for mild-to-moderate insertional Achilles tendinopathy (IAT) with Haglund deformity remains controversial. This study compares the clinical and radiological outcomes of Zadek Calcaneal Closing Wedge Osteotomy (ZCCWO) and Calcaneal Exostectomy with Tendon Repair (CE-TR). Material and methods. This retrospective study included 30 patients (15 ZCCWO, 15 CE-TR) with mild-to-moderate IAT associated with calcaneal exostosis. Clinical outcomes were assessed using the American Orthopaedic Foot & Ankle Society (AOFAS) Ankle-Hindfoot Score and Numeric Pain Rating Scale (NPRS). Radiological evaluations included the Fowler–Phillip (FP), Calcaneal Pitch (CP), and Chaveaux-Liet (CL) angles. The mean follow-up was 39 ± 8.8 months (ZCCWO) and 31.4 ± 5 months (CE-TR). Results. Both groups demonstrated significant improvements in AOFAS and NPRS scores (P < .00001) with no statistically significant differences between them (AOFAS: P = .6, NPRS: P = .65). The postoperative decline in FP angle was comparable (ZCCWO: 10.1°±3.9°, CE-TR: 9.7°±4.4°; P > .05). Non-union occurred in 1 ZCCWO case (6.6%), while superficial wound infections were more common in the CE-TR group (13.3% vs 6.6%). Conclusion. The ZCCWO and CE-TR provide equivalent functional and radiological outcomes for mild-to-moderate IAT associated with Haglund deformity. Both procedures are effective and safe, with complication profiles that warrant consideration in surgical planning.
MaffulliNSaxenaAWagnerETorreG.Achilles insertional tendinopathy: state of the art. J ISAKOS. 2019;4(1):48-57.
3.
ZhangQCaiYHuaYShiJWangYWangY.Sonoelastography shows that Achilles tendons with insertional tendinopathy are harder than asymptomatic tendons. Knee Surg Sports Traumatol Arthrosc. 2017;25(6):1839-1848.
4.
WiegerinckJIKerkhoffsGMvan SterkenburgMNSiereveltINvan DijkCN.Treatment for insertional Achilles tendinopathy: a systematic review. Knee Surg Sports Traumatol Arthrosc. 2013;21(6):1345-1355. doi:10.1007/s00167-012-2219-8
5.
KangSThordarsonDBCharltonTP.Insertional Achilles tendinitis and Haglund’s deformity. Foot Ankle Int. 2012;33(6):487-491.
6.
MyersonCLShimozonoYKennedyJG.Haglund’s deformity and chronic Achilles tendonitis. Oper Tech Orthop. 2018;28(2):104-109.
SharmaPMaffulliN.Biology of tendon injury: healing, modeling and remodeling. J Musculoskelet Neuronal Interact. 2006;6(2):181-190.
9.
SederbergMCushmanDM.Current treatments of insertional Achilles tendinopathy. Curr Phys Med Rehabil Rep. 2020;8:354-363.
10.
StensonJFRebCWDanielJNSainiSSAlbanaMF.Predicting failure of nonoperative treatment for insertional Achilles tendinosis. Foot Ankle Spec. 2018;11(3):252-255.
11.
OshriYPalmanovichEBrinYS, et al. Chronic insertional Achilles tendinopathy: surgical outcomes. Muscles Ligaments Tendons J. 2012;2(2):91-95.
12.
YuenWLPTanPTKonKKC. Surgical treatment of Haglund’s deformity: a systematic review and meta-analysis. Cureus. 2022;14(7):e27500. doi:10.7759/cureus.27500
KaraismailogluBAltunASSubasiO, et al. Comparison between Achilles tendon reinsertion and dorsal closing wedge calcaneal osteotomy for the treatment of insertional Achilles tendinopathy: a meta-analysis. Foot Ankle Surg. 2024;30(2):92-98. doi:10.1016/j.fas.2023.09.010
15.
BlackATSoECombsALoganD.The Zadek osteotomy for surgical management of insertional Achilles tendinopathy: a systematic review. Foot Ankle Spec. 2023;16(4):437-445. doi:10.1177/19386400231162411
16.
SinghRRohillaRSiwachRCMaguNKSangwanSSSharmaA.Diagnostic significance of radiologic measurements in posterior heel pain. Foot (Edinb). 2008;18(2):91-98. doi:10.1016/j.foot.2008.01.005
17.
ChauveauxDLietPLe HuecJCMidyD.A new radiologic measurement for the diagnosis of Haglund’s deformity. Surg Radiol Anat. 1991;13(1):39-44. doi:10.1007/BF01623140
18.
FowlerAPhilipJF.Abnormality of the calcaneus as a cause of painful heel its diagnosis and operative treatment. Br J Surg. 1945;32(128):494-498. doi:10.1002/bjs.18003212812
19.
ChildsJDPivaSRFritzJM.Responsiveness of the numeric pain rating scale in patients with low back pain. Spine (Phila Pa 1976). 2005;30(11):1331-1334. doi:10.1097/01.brs.0000164099.92112.29
20.
RodriguezCS.Pain measurement in the elderly: a review. Pain Manag Nurs. 2001;2(2):38-46. doi:10.1053/jpmn.2001.23746
21.
GowdaBNKumarJM.Outcome of ankle arthrodesis in posttraumatic arthritis. Indian J Orthop. 2012;46(3):317-320. doi:10.4103/0019-5413.96392
22.
KitaokaHBAlexanderIJAdelaarRSNunleyJAMyersonMSSandersM.Clinical rating systems for the ankle-hindfoot, midfoot, hallux, and lesser toes. Foot Ankle Int. 1994;15(7):349-353. doi:10.1177/107110079401500701
23.
RousseauRGeromettaAFogertySRollandECatonnéYKhiamiF.Results of surgical treatment of calcaneus insertional tendinopathy in middle- and long-distance runners. Knee Surg Sports Traumatol Arthrosc. 2015;23(9):2494-2501. doi:10.1007/s00167-014-2986-5
24.
GeZMaLTangH, et al. Comparison of dorsal closing wedge calcaneal osteotomy versus posterosuperior prominence resection for the treatment of Haglund syndrome. J Orthop Surg Res. 2020;15(1):168. doi:10.1186/s13018-020-01687-6
25.
LinCMaLChenW, et al. [A comparative study of the calcaneal closing-wedge calcaneal osteotomy versus posterior-superior prominence removal in both sides with Haglund syndrome]. Zhonghua Yi Xue Za Zhi. 2017;97(35):2733-2736. doi:10.3760/cma.j.Issn.0376-2491.2017.35.004
26.
XuYHaiderZAKaruppiahVDharS.Zadek osteotomy, a good treatment option for refractory Haglund’s deformity. Cureus. 2023;15(5):e39497. doi:10.7759/cureus.39497
27.
FriesenbichlerBRutishauerTRippsteinP, et al. Ankle muscle strength and gait function after dorsal closing wedge calcaneal osteotomy for Haglund exostosis-related heel pain. Foot Ankle Int. 2024;45(7):701-710. doi:10.1177/10711007241241264
28.
CengizBKaraogluS.Clinical results of the Keck and Kelly Wedge Osteotomy approach in Haglund’s deformity: minimum 3-year follow-up. Foot Ankle Surg. 2022;28(2):269-275. doi:10.1016/j.fas.2021.10.006
29.
TourneYBarayALBarthelemyRKarhaoTMoroneyP.The Zadek calcaneal osteotomy in Haglund’s syndrome of the heel: clinical results and a radiographic analysis to explain its efficacy. Foot Ankle Surg. 2022;28(1):79-87. doi:10.1016/j.fas.2021.02.001
30.
TournéYFranconyFBarthélémyRKarhaoTMoroneyP.The Zadek calcaneal osteotomy in Haglund’s syndrome of the heel: its effects on the dorsiflexion of the ankle and correlations to clinical and functional scores. Foot Ankle Surg. 2022;28(6):789-794. doi:10.1016/j.fas.2021.11.001
31.
MaffulliNGougouliasND’AddonaAOlivaFMaffulliGD.Modified Zadek osteotomy without excision of the intratendinous calcific deposit is effective for the surgical treatment of calcific insertional Achilles tendinopathy. Surgeon. 2021;19(6):e344-e352. doi:10.1016/j.surge.2020.08.018
32.
MaffulliND’AddonaAGougouliasNOlivaFMaffulliGD.Dorsally based closing wedge osteotomy of the calcaneus for insertional Achilles tendinopathy. Orthop J Sports Med. 2020;8(3):2325967120907985. doi:10.1177/2325967120907985
33.
López-CapdevilaLSantamaria FumasADominguez SevillaA, et al. Dorsal wedge calcaneal osteotomy as surgical treatment for insertional Achilles tendinopathy [Osteotomía calcánea con cuña de sustracción dorsal como tratamiento quirúrgico en la tendinopatía insercional de Aquiles]. Rev Esp Cir Ortop Traumatol (Engl Ed). 2020;64(1):22-27. doi:10.1016/j.recot.2019.09.004
34.
GeorgiannosDLampridisVVasiliadisABisbinasI.Treatment of insertional Achilles pathology with dorsal wedge calcaneal osteotomy in athletes. Foot Ankle Int. 2017;38(4):381-387. doi:10.1177/1071100716681139
35.
Abarquero-DiezhandinoAVacas-SánchezEHernanz-GonzálezYVilá-RicoJ.Study of the clinical and functional results of open calcaneoplasty and tendinous repair for the treatment of the insertional tendinopathy of the Achilles’ tendon [Estudio de los resultados clínico-funcionales de la calcaneoplastia abierta y reparación tendinosa con sistema de cinta y doble hilera en el tratamiento de la tendinopatía insercional del tendón de Aquiles]. Rev Esp Cir Ortop Traumatol (Engl Ed). 2021;65(1):47-53. doi:10.1016/j.recot.2020.07.003
36.
CatesNKWaglerECChenSRubinLG.Retrocalcaneal enthesophyte resection with functional lengthening of the Achilles tendon and buried knot technique: a case series. J Foot Ankle Surg. 2021;60(6):1308-1314. doi:10.1053/j.jfas.2021.07.010
37.
ScottATLongCSJaramilloTJLaraDLMaroisAJJunejaP.Review of Achilles tendon reattachment using double-row knotted and knotless techniques in the management of insertional Achilles tendinopathy. J Foot Ankle Surg. 2022;61(5):927-931. doi:10.1053/j.jfas.2021.12.015
38.
XiaZYewAKSZhangTKSuHCDNgYCSRikhrajIS.Surgical correction of Haglund’s triad using a central tendon-splitting approach: a retrospective outcomes study. J Foot Ankle Surg. 2017;56(6):1132-1138. doi:10.1053/j.jfas.2017.05.015
39.
EttingerSRazzaqRWaizyH, et al. Operative treatment of the insertional Achilles tendinopathy through a transtendinous approach. Foot Ankle Int. 2016;37(3):288-293. doi:10.1177/1071100715609921
40.
LinHAChongHAYeoW.Calcaneoplasty and reattachment of the Achilles tendon for insertional tendinopathy. J Orthop Surg (Hong Kong). 2014;22(1):56-59. doi:10.1177/230949901402200115
41.
MaffulliNTestaVCapassoGSulloA.Calcific insertional Achilles tendinopathy: reattachment with bone anchors. Am J Sports Med. 2004;32(1):174-182. doi:10.1177/0363546503258923
42.
BellasNNayakRPashaM, et al. Biomechanical changes to the Hindfoot after Zadek osteotomy. Foot Ankle Int. 2024;45(12):1406-1413. doi:10.1177/10711007241281737
43.
LuCCChengYMFuYCTienYCChenSKHuangPJ.Angle analysis of Haglund syndrome and its relationship with osseous variations and Achilles tendon calcification. Foot Ankle Int. 2007;28(2):181-185. doi:10.3113/fai.2007.0181
44.
PavlovHHeneghanMAHershAGoldmanABVigoritaV.The Haglund syndrome: initial and differential diagnosis. Radiology. 1982;144(1):83-88.
45.
WardERAnderssonGBackmanLJGaidaJE.Fat pads adjacent to tendinopathy: more than a coincidence. Br J Sports Med. 2016;50(24):1491-1492. doi:10.1136/bjsports-2016-096174
46.
AckermannPWPhisitkulPPearceCJ.Achilles tendinopathy—pathophysiology: state of the art. Journal of ISAKOS. 2018;3(5):304-314. doi:10.1136/jisakos-2017-000164
47.
ZellersJAEekhoffJDWalkREHastingsMKTangSYLakeSP.Human Achilles tendon mechanical behavior is more strongly related to collagen disorganization than advanced glycation end-products content. Sci Rep. 2021;11(1):24147. doi:10.1038/s41598-021-03574-4
48.
CouppéCSvenssonRBKongsgaardM, et al. Human Achilles tendon glycation and function in diabetes. J Appl Physiol (1985). 2016;120(2):130-137. doi:10.1152/japplphysiol.00547.2015
49.
BoffeliTJPetersonMC.The Keck and Kelly wedge calcaneal osteotomy for Haglund’s deformity: a technique for reproducible results. J Foot Ankle Surg. 2012;51(3):398-401. doi:10.1053/j.jfas.2012.03.002
50.
GeorgiannosDKitridisDBisbinasI.Dorsal closing wedge calcaneal osteotomy for the treatment of insertional Achilles tendinopathy: a technical tip to optimize its results and reduce complications. Foot Ankle Surg. 2018;24(2):115-118. doi:10.1016/j.fas.2016.12.004
51.
CardoneGBilbaoFVerbnerJMCafruniVMCarrascoMN.Endoscopic calcaneoplasty in Haglund disease: surgical technique, clinical and subjective outcomes. Foot Ankle Int. 2024;45(10):1076-1082. doi:10.1177/10711007241264223
52.
KohJRDKonCKKChandrakumaraSBMD.Endoscopic calcaneoplasty with bony debridement and radiofrequency. Arthrosc Tech. 2024;13(4):102912. doi:10.1016/j.eats.2024.102912
53.
OpdamKTMZwiersRVroemenJSiereveltINWiegerinckJIvan DijkCN. High patient satisfaction and good long-term functional outcome after endoscopic calcaneoplasty in patients with retrocalcaneal bursitis. Knee Surg Sports Traumatol Arthrosc. 2021;29(5):1494-1501. doi:10.1007/s00167-020-06167-2
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