Open vs Endoscopic Surgical Treatment for Haglund Deformity: A Systematic Review,Meta-analysis,and Meta-regression

Abstract

Background:

Haglund deformity, characterized by a bony prominence at the posterosuperior aspect of the calcaneus, is a frequent cause of posterior heel pain and Achilles tendinopathy. When conservative treatment fails, surgical resection is indicated. This systematic review and meta-analysis aimed to compare clinical and functional outcomes of open and endoscopic surgery in adults with Haglund deformity.

Methods:

The review followed PRISMA guidelines, was registered in PROSPERO (CRD420251061639), and included randomized trials or observational cohort studies directly comparing both techniques. The primary outcome was postoperative ankle function (American Orthopaedic Foot & Ankle Society score or the Victorian Institute of Sports Assessment–Achilles questionnaire scores); secondary outcomes included operative time, postoperative pain (visual analog scale), and adverse events. Random effects (restricted maximum likelihood) meta-analyses were performed, and risk of bias was assessed using the ROBINS-I tool.

Results:

Five cohort studies, totaling 226 patients (127 endoscopic, 99 open), met the inclusion criteria. The meta-analysis showed no significant difference in postoperative ankle function between techniques (standardized mean difference = −0.19, 95% CI −0.72 to 0.35; I² = 66.7%). Operative time was shorter in the open surgery group (mean difference = −11.73 minutes, 95% CI −23.03 to −0.42; I² = 94.6%). No significant differences were observed in postoperative pain or adverse events. All studies had a serious overall risk of bias.

Conclusion:

The available comparative observational evidence does not demonstrate clear superiority of either technique for the evaluated outcomes. Interpretation of symptom and function outcomes is limited by the measurement properties of the instruments used in the source studies. These findings represent a conservative synthesis of the best comparative evidence currently available and highlight the need for adequately powered randomized clinical trials with standardized outcome measures to more reliably inform surgical decision making.

Keywords

Haglund deformity endoscopy orthopedic procedures calcaneus minimally invasive surgical procedures

Introduction

Haglund deformity (HD), or retrocalcaneal exostosis, is a bony enlargement at the posterosuperior calcaneus at the Achilles insertion.¹ It commonly causes retrocalcaneal bursitis and insertional Achilles tendinopathy, leading to posterior heel pain, swelling, and functional limitation.¹ Predisposing factors include foot malalignment and rigid-heeled footwear, which increase retrocalcaneal pressure and friction.² Young, active individuals, particularly women, are more often affected, and bilateral involvement is frequent.² Persistent symptoms may progress to chronic bursitis and degenerative changes in the Achilles tendon, impairing ambulation and quality of life.³

The initial management of HD is conservative, involving shoe wear and activity modifications, heel lifts, nonsteroidal anti-inflammatory drugs, and physical therapy (stretching and strengthening gastrocnemius and soleus protocols) to reduce inflammation and mechanical stress. Although such measures may alleviate symptoms and address secondary bursitis, they do not alter the underlying bony morphology.⁴ In cases where conservative treatment fails to provide adequate relief, surgical intervention is warranted, typically consisting of resection of the calcaneal prominence and debridement of the inflamed bursa.⁵

The 2 predominant surgical techniques are open and endoscopic calcaneoplasty. Both aim to restore function and reduce pain, and current literature suggests potential advantages of the endoscopic approach, such as reduced operative morbidity, fewer wound complications, and faster return to activity.^6,7 In addition, other surgical strategies have been increasingly reported in selected cases, including dorsal closing-wedge calcaneal osteotomy (Zadek osteotomy), performed through open or percutaneous techniques, as an alternative approach aimed at modifying calcaneal morphology and reducing insertional load.⁸ However, heterogeneity in surgical techniques and outcome reporting limits firm conclusions.

Although a previous systematic review attempted to summarize the surgical treatment of HD, it presented important methodologic flaws that limit its applicability to clinical decision-making.⁹ Notably, the authors employed a single-arm meta-analysis design, evaluating open and endoscopic procedures separately, without directly comparing outcomes, precluding any valid inference on relative effectiveness.⁹ Therefore, this systematic review and meta-analysis aims to compare open and endoscopic surgical techniques for HD treatment regarding functional outcomes and complication rates.

Methods

This systematic review and meta-analysis followed PRISMA guidelines.¹⁰ The primary objective was to compare the clinical and functional outcomes of open vs endoscopic surgical treatment in adult patients with HD. The PICOTT framework was defined as follows: Population (P): adults diagnosed with HD undergoing surgical intervention; Intervention (I): endoscopic surgical treatment (eg, endoscopic calcaneoplasty or similar minimally invasive techniques); Comparison (C): open surgical treatment (eg, traditional calcaneal exostectomy); Outcomes (O): primary—postoperative ankle function, measured by validated scales such as the American Orthopaedic Foot & Ankle Society (AOFAS) score or the Victorian Institute of Sports Assessment–Achilles (VISA-A) questionnaire; secondary—operative time (minutes), postoperative pain (visual analog scale), and adverse events (infection, nerve injury, wound complications, among others); Type of study (T): randomized controlled trials and observational cohort studies (prospective or retrospective); Time (T): any length of follow-up. This review was registered in the PROSPERO under the registration number CRD420251061639. The methodology was defined and submitted prior to the database search.

Eligibility Criteria

Eligible studies were full-text articles published in English, available in PubMed, Scopus, Embase, and Cochrane CENTRAL until June 2025. Studies were required to compare open and endoscopic surgical approaches for HD and to report at least 1 predefined clinical outcome.

Exclusion criteria included conference abstracts, preprints, letters to the editor, case reports and case series, cross-sectional and case-control studies, animal or cadaveric models, and studies without extractable data on relevant outcomes. In cases of duplicate publications, only the most complete version was retained.

Search Strategy

For the database search, descriptors related to “Haglund’s Deformity,” “Endoscopy Surgical,” and “Open Surgery,” obtained from the Medical Subject Headings (MeSH) vocabulary and related keywords. Boolean operators AND and OR were applied to combine terms across databases according to the predefined inclusion and exclusion criteria. All descriptors and complete search strategies for each database are available in Supplementary Material.

Selection of Studies

Two independent reviewers (CRAJ and ESRB) screened titles and abstracts of all retrieved articles to identify those meeting the inclusion criteria. Potentially, eligible studies were read in full to confirm inclusion. In cases of disagreement, a senior reviewer (ESRM), who had access only to the disputed articles, made the final decision. Study selection was conducted using Rayyan (Rayyan QCRI, Doha, Qatar).¹¹

Data Summarization

Data extraction was performed independently and in duplicate (CRAJ and ESRB) to ensure accuracy and reliability. Two reviewers extracted data from the included studies using a predesigned data extraction form created in Microsoft Excel^® (version 2205). The form captured comprehensive details on study characteristics, including population size, intervention and control group specifics, methodologic approaches, and the outcomes assessed. Any reviewer discrepancies were resolved through discussion or consultation with a senior reviewer (AG) to achieve consensus.

Quality Assessment

Two reviewers assessed the ROBINS-I for cohort studies.¹² Publication bias was investigated through contour-enhanced funnel plots and Egger regression test.¹³

Statistical Analysis

The primary outcome was ankle function, analyzed as a continuous variable. As different validated scales were used, results were synthesized using the standardized mean difference (SMD) with 95% CIs. When all included studies used the same scale, a subgroup analysis was performed using the mean difference (MD). Secondary continuous outcomes (operative time and postoperative pain) were also analyzed using MD. Adverse events were treated as dichotomous outcomes and analyzed using risk ratios (RRs) with 95% CIs. When results were reported as median and IQR, the values were converted to mean and SD using the methods described by Luo et al¹⁴ and Wan et al,¹⁵ respectively.

Heterogeneity was assessed using the Cochran Q test and the I² statistic, with P values <.10 and I² >25% considered indicative of substantial heterogeneity. Prediction intervals (PIs) were additionally reported to express the expected range of effect sizes across similar future studies.¹⁶ Given the clinical and methodologic variability among the included studies, all meta-analyses were conducted using a random-effects model, applying the restricted maximum likelihood estimator.

Univariable meta-regression analyses were performed to explore the impact of potential moderator variables on standardized postoperative functional scores. The covariates assessed included study design (prospective vs retrospective), baseline functional score, and mean participant age. Each model was fitted using a random-effects approach with estimation via the restricted maximum likelihood method. We reported effect estimates, P values, and residual heterogeneity for each model, and statistical significance was defined as P <.05.

Leave-one-out sensitivity analyses were conducted for all outcomes to assess the robustness of the findings. For the primary outcome, we additionally back-transformed the pooled SMD to the AOFAS scale using the average SD of included studies, allowing interpretation in clinical terms. Publication bias for the primary outcome was evaluated through contour-enhanced funnel plots and Egger regression test, with P <.05 indicating potential asymmetry. All statistical analyses were conducted in RStudio, version 764, using the meta and metafor packages.

Results

The database search identified 664 records. After removing duplicate records, 552 articles remained for screening. Title and abstract screening resulted in the exclusion of 512 records, and 40 full-text articles were subsequently assessed for eligibility. Of these, five studies met the inclusion criteria and were included in meta-analysis. The study selection process and detailed reasons for exclusion at each stage are illustrated in Figure 1.

Figure 1.

PRISMA Flow Diagram.

Characteristics of the Studies

Five cohort studies (2 prospective and 3 retrospective), including 226 patients with clinically and radiographically confirmed Haglund deformity or insertional Achilles tendinopathy, were analyzed (127 endoscopic, 99 open).^17-21 The studies were conducted in India, Egypt, the United States, China, and France, and generally enrolled adults with symptoms persisting for ≥6 months despite conservative treatment. Diagnosis was based on clinical and radiographic findings, with MRI additionally used in 2 studies. Mean age ranged from young to middle-aged adults, with a slight male predominance. Endoscopic procedures were performed through 2 or 3 portals under direct or fluoroscopic visualization, whereas open surgery used lateral or posterolateral approaches with resection of the calcaneal prominence. Preoperative function was assessed with the AOFAS score in 4 studies and the VISA-A questionnaire in one study. Further methodologic and clinical details are summarized in Table 1.

Table 1.

Main Characteristics.

Study	Population	Endoscopic Surgical	Open Surgical	Country Study	Design	Follow-up(mo)	Number of Patients (M/F)		Age (y)		Symptom DurationBefore Surgery (mo)		Preoperative Function Score
Study	Population	Endoscopic Surgical	Open Surgical	Country Study	Design	Follow-up(mo)	Endoscopic	Open	Endoscopic	Open	Endoscopic	Open	Endoscopic	Open
Appala Raju et al (2015)¹⁷	Adults with clinically and radiographically confirmed Haglund deformity, symptomatic for >7 mo despite physical therapy, analgesics, and heel support, all presented with painful posterior heel swelling.	Prone position, tourniquet applied, 2 portals (medial and lateral). Bursa resected with shaver; bone prominence removed with burr under direct view and fluoroscopy. Portals alternated; Achilles tendon preserved.	Prone position; “J”-shaped incision along the lateral border of the Achilles tendon, anterior dissection, and resection of the calcaneal tuberosity with an osteotome. Layered closure, compressive dressing, and immobilization with a splint.	India	Prospective cohort	12^a	1/8	2/4	35^a		9 ± 2^b		21.55^a,c	23.66^a,c
Mansour (2017)¹⁹	Adults with clinically and radiographically confirmed Haglund deformity, posterior heel pain persisting for ≥6 mo, functional limitation, and surgical indication.	Prone position under general or spinal anesthesia with a tourniquet. Two or 3 portals (typically medial and lateral or superior) were used. The retrocalcaneal bursa and posterosuperior calcaneal prominence were resected with a burr under direct and fluoroscopic guidance, preserving the Achilles tendon.	Prone position; longitudinal lateral incision over the calcaneus, with careful dissection and retraction of the Achilles tendon. Resection of the posterosuperior prominence using an osteotome or burr. Irrigation, layered closure, and immobilization in plantar flexion.	Egypt	Prospective cohort	E: 26.53 ± 3.22^b O: 20.76 ± 3.66^b	5/9	4/8	33.01 ± 7.61^b	35.43 ± 9.78^b	29.60 ± 9.48^b	26.21 ± 12.84^b	63.4^a,c	61.1^a,c
Cusumano et al (2021)¹⁸	Adults with persistent posterior heel pain due to Haglund deformity, confirmed clinically and radiographically, refractory to conservative treatment; cases with hindfoot deformities or prior surgeries were excluded.	Prone position with 2 arthroscopic portals (medial and lateral). Bursa debrided with shaver; bony prominence resected with motorized burr under direct vision. Fluoroscopy used intraoperatively; Achilles tendon preserved.	Prone position; lateral incision over the calcaneus, direct dissection, and resection of the exostosis using an osteotome.	USA	Retrospective cohort	E: 39.9 ± 23.7^b O: 66.8 ± 24.0^b	14/12	14/12	48.3 ± 8.9^b	49.6 ± 9.6^b	NR		66.69 ± 7.19^b,c	65.67 ± 10.09^b,c
Pi et al (2021)²⁰	Adults with clinically and MRI-confirmed Haglund syndrome, symptomatic for ≥6 mo and unresponsive to conservative treatment; included only cases with <50% tendon degeneration.	Prone, under general or spinal anesthesia with a tourniquet. Two portals (medial and lateral). Bursa debrided with shaver; osteophyte resected with burr under direct view. Portal switching for access; fluoroscopic guidance used; Achilles tendon preserved.	Prone position; lateral incision adjacent to the Achilles tendon with tendon retraction. Resection performed using an osteotome and burr under fluoroscopic guidance. Layered closure and immobilization in plantar flexion; Achilles tendon preserved.	China	Retrospective cohort	E: 35.81 ± 19.48^b O: 41.35 ± 15.70^b	21/6	15/6	35.6 ± 12.8^b	38.5 ± 11.0^b	30.25 ± 20.23^b	29.57 ± 25.83^b	NR	NR
Thiounn et al (2025)²¹	Adults with insertional Achilles tendinopathy confirmed by clinical examination and MRI, symptomatic for ≥6 mo, and refractory to conservative management.	Endoscopic calcaneoplasty using an arthroscope with portal inversion as needed for precise resection of the calcaneal tuberosity, aiming to minimize soft tissue injury and postoperative complications.	Prone position; direct resection of the calcaneal prominence using osteotome and powered burr under direct visualization, preserving the Achilles insertion. Fluoroscopic assessment post-resection, followed by layered closure and plantar flexion immobilization.	France	Retrospective cohort	12^a	51	34	46.94 ± 12.27^b	52.48 ± 12.36^b	NR		41.36 ± 18.02^b,d	33.81 ± 20.39^b,d

Abbreviations: E, endoscopic group; F, female; M, male; MRI, magnetic resonance imaging; NR, not reported; O, open group; .

Median.

Mean ± SD.

American Orthopaedic Foot & Ankle Society Score.

Victorian Institute of Sport Assessment–Achilles.

Function of the Ankle

Five studies, including a total of 226 patients, assessed postoperative ankle function. Appala Raju et al,¹⁷ Cusumano et al,¹⁸ Mansour,¹⁹ and Pi et al²⁰ evaluated outcomes using the AOFAS score, whereas Thiounn et al.²¹ used the VISA-A questionnaire. The pooled analysis revealed no statistically significant difference between the open and endoscopic groups (SMD = −0.19; 95% CI: −0.72 to 0.35; PI: −1.78 to 1.41; P = .498; I² = 66.7%) (Figure 2A). The leave-one-out sensitivity analysis did not identify any substantial change in effect size or statistical significance on exclusion of individual studies (Figure 2B).

Figure 2.

Analysis of Postoperative Ankle Function. (A) Forest plot of the pooled analysis for postoperative ankle function (AOFAS and VISA-A combined). (B) Leave-1-out sensitivity analysis of postoperative ankle function (AOFAS and VISA-A combined). (C) Function of the ankle (restricted to studies using the AOFAS).

The AOFAS score ranges from 0 to 100, with higher values indicating better ankle and hindfoot function. However, there is no universally established minimal clinically important difference (MCID) for the AOFAS Ankle-Hindfoot score, and reported estimates vary according to the studied population, underlying pathology, and methodologic approach used for its determination.^22-25 To aid interpretation, we back-translated the pooled SMD to the AOFAS scale using the average SD of the included studies (approximately 9 points), obtaining an estimated mean difference of −1.7 points (95% CI −6.5 to 3.2), well below the usual MCID threshold.

Three univariable meta-regressions were performed. Prospective design was significantly associated with higher standardized postoperative scores (coefficient = 1.0780; 95% CI: 0.2979-1.8582; P = .0068) (Figure S1 and Table S1). No significant associations were found for baseline functional score (P = .9687) (Figure S2 and Table S2) or mean age (P = .4736) (Figure S3 and Table S3).

Egger regression test was not statistically significant (t = −1.58; P = .213), indicating no strong evidence of small-study or publication bias in this analysis (Figure S4 and Table S4).

Function of the Ankle (AOFAS Subgroup Analysis)

Four studies (212 patients) assessed postoperative ankle function exclusively using the AOFAS score.^18-21 The pooled analysis showed no statistically significant difference between the open and endoscopic approaches (MD = −0.85; 95% CI: −6.25 to 4.55; PI: −17.80 to 16.10; P = .758; I² = 73.2%) (Figure 2C). In the leave-one-out sensitivity analysis, excluding Mansour ¹⁹ reduced heterogeneity (I² = 38.9%) and shifted the effect estimate toward the endoscopic group (MD = 1.58; 95% CI: −2.70 to 5.87), but results remained nonsignificant (Figure S5).

Operative Time

Three studies (127 patients) reported on operative time in minutes.^18-20 The pooled analysis showed a statistically significant difference favoring the open approach (MD = −11.73; 95% CI: −23.03 to −0.42; PI: −59.61 to 36.15; P = .042; I² = 94.6%) (Figure 3A). The leave-one-out sensitivity analysis demonstrated that the exclusion of Mansour¹⁹ or Pi et al²⁰ led to loss of statistical significance, highlighting the influence of these studies on the overall effect (Figure 3B).

Figure 3.

Analysis of operative time. (A) Forest plot of the pooled analysis for operative time. (B) Leave-one-out sensitivity analysis of operative time.

Postoperative Pain

Two studies (101 patients) reported postoperative pain using the visual analog scale.^18,20 The meta-analysis showed no statistically significant difference between groups (MD = −0.52; 95% CI: −1.30 to 0.27; PI: −5.61 to 4.58; P = .197; I² = 0%) (Figure S6). However, this estimate is based on only 2 comparative studies, limiting statistical precision. Leave-one-out analysis did not meaningfully change the effect size or its significance (Figure S7).

Postoperative Adverse Events

Five studies (222 patients) reported on postoperative adverse events.^17-21 The pooled analysis showed no statistically significant difference between the open and endoscopic groups (RR = 1.86; 95% CI: 0.63 to 5.51; PI: 0.28 to 12.21; P = .262; I² = 7.6%) (Figure 4A). Leave-one-out analysis did not produce substantial changes in effect size or significance (Figure 4B).

Figure 4.

Analysis of postoperative adverse events. (A) Forest plot of the pooled analysis for postoperative adverse events. (B) Leave-one-out sensitivity analysis of postoperative adverse events.

Complications were generally infrequent and heterogeneous. Infections occurred in both groups, without a clear predominance. Sensory disturbances and scar tenderness were reported mainly after open surgery, whereas delayed wound healing and pre-Achilles bursitis appeared in both groups, and only 1 acute Achilles tendon rupture was described in the open group. No consistent association pattern between adverse events and surgical approach was identified, in line with the absence of statistically significant differences in the meta-analysis. Study-level adverse events by type are summarized in Table 2.

Table 2.

Detailed Description of Adverse Events and Complications Reported in the Included Comparative Studies.

Study	Open surgery (n)^a	Endoscopic surgery (n)^a	Clinical details
Appala Raju et al (2015)¹⁷	—	Surgical site infection (1)	Infection reported as grade IVb; no wound-healing problems reported in the endoscopic group
Mansour (2017)¹⁹	Infection (1); sensory disturbance/paresthesia (4); scar tenderness (3)	Sensory disturbance/paresthesia (1); scar tenderness (1)	—
Cusumano et al (2021)¹⁸	Acute Achilles tendon rupture (1)	Infection (2)	—
Pi et al (2021)²⁰	Sensory disturbance/paresthesia (2)	—	Symptoms consistent with sural nerve involvement; complete recovery by 6 months; no complications in endoscopic group
Thiounn et al (2025)²¹	Delayed wound healing (2)	Delayed wound healing (1); symptomatic pre-Achilles bursitis (1)	Time points: delayed healing at 1 mo; bursitis at 6 mo

n = number of reported events, as described in the original studies.

Risk of Bias of the Included Studies

All studies were rated as having a serious overall risk of bias.^17-21 The domain of confounding (D1) was consistently judged as serious because of the absence of statistical adjustment for baseline characteristics such as symptom duration, functional level, or treatment preference.^17-21 Participant selection (D2) was rated moderate in all studies, given the non-randomized designs and potential baseline imbalances.^17-21 Intervention classification (D3) was low risk, as procedures were well defined and distinguishable.^17-21 Deviations from intended interventions (D4) were moderate in most studies because of protocol differences in postoperative care.^17-19,21 Risk of bias from missing data (D5) was rated moderate in Pi et al²⁰ and Thiounn et al²¹ because of incomplete follow-up without sensitivity analysis, whereas it was low in the others with complete outcome reporting. Outcome measurement (D6) was rated moderate in all studies because outcome assessors were not blinded.^17-21 Selective reporting (D7) was moderate in 4 studies because of a lack of pre-registration or unclear reporting criteria,^17-20 and low in Thiounn et al,²¹ which reported complete results across time points. The risk of bias is summarized in Figure 5.

Figure 5.

Risk of bias assessment. (A) Summary plot of bias analysis. (B) Traffic light plot of bias analysis.

Discussion

Our meta-analysis found no statistically or clinically meaningful difference in postoperative functional outcomes between open and endoscopic approaches. Although minimally invasive techniques are commonly associated with improved functional recovery, reduced soft tissue trauma, and earlier return to activities, our findings diverge from this expected trend.²⁶ A previous systematic review by Alessio-Mazzola et al,²⁷ which included more than 1200 patients, reported modest but statistically significant advantages of endoscopic surgery in AOFAS scores and complication rates; however, these findings are weakened by important methodologic issues.

The review pooled comparative and single-arm studies and performed separate meta-analyses for open and endoscopic series without direct between-group comparison,²⁷ which prevents valid inference and may exaggerate effects in favor of the newer technique.²⁸ The inclusion of uncontrolled case series, highly susceptible to selection and publication bias, further undermines the reliability of its conclusions, and case series are known to overestimate treatment effects compared with controlled designs across several surgical fields.^29,30 By restricting our synthesis to controlled studies and applying a direct comparative meta-analytic model, we sought to address these limitations; based on the available evidence, endoscopic techniques remain promising but cannot be considered clearly superior to the open approach.

More recently, Chen et al³¹ published a systematic review and meta-analysis including 39 studies and 1559 patients undergoing open or endoscopic surgery for insertional Achilles tendinopathy. Most included studies consisted of observational case series, with only 5 providing direct comparisons between techniques. The authors reported functional improvement with both approaches, with no significant difference in AOFAS scores between open and endoscopic surgery. They also suggested lower complication rates and faster recovery with the endoscopic technique, including earlier return to daily activities and sports. These potential benefits, however, should be interpreted with caution, given the predominance of noncontrolled studies and the limited number of direct comparisons. Accordingly, although the review provides a relevant synthesis of the available literature, its conclusions remain contingent on confirmation in well-designed comparative studies with standardized outcome reporting.

A portion of the available evidence assessed postoperative function and pain using the AOFAS Clinical Rating Systems and the VISA-A score. As emphasized in official AOFAS position statements, the AOFAS clinical scoring systems have important limitations in validity, reliability, and interpretability and are therefore not recommended as primary outcome measures in contemporary prospective research.^32,33 Similarly, although VISA-A is a widely used patient-reported measure for Achilles tendinopathy, recent psychometric evaluation has identified meaningful limitations, particularly regarding content validity and the use of the total score as a unidimensional construct.³⁴

In our synthesis, postoperative functional and pain outcomes were broadly comparable between open and endoscopic procedures, but pain estimates were imprecise (wide confidence and prediction intervals) and reported by only 2 comparative studies. This aligns with prior syntheses suggesting that both techniques improve postoperative pain, without consistent evidence of superiority in pain resolution.⁹ Accordingly, function- and pain-related findings should be interpreted conservatively and understood primarily in the context of measurement limitations and sparse comparative data within the source literature.^32-34

Contrary to expectations that minimally invasive surgery would reduce operative time, our pooled analysis initially suggested shorter operative times for open procedures. However, heterogeneity was extremely high, prediction intervals were very wide, and statistical significance disappeared when individual studies were omitted. This pattern contrasts with numerous reports indicating similar or shorter endoscopy durations once the learning curve is surpassed.^35,36 The cadaveric study by Roth et al³⁷ also suggested that open resection may achieve greater bone removal more rapidly. Contemporary observational and technique papers increasingly emphasize that endoscopic calcaneoplasty demands significant technical proficiency and intraoperative imaging guidance (eg, fluoroscopy).³⁸ Thus, longer operative durations in our review likely reflect procedural inexperience and variability in surgeon familiarity rather than true inefficiency of the endoscopic technique, underscoring the importance of considering learning curve and institutional experience when interpreting operative time differences.

Although endoscopic methods are often promoted for reduced soft tissue trauma and faster symptomatic resolution, these benefits may be offset by variables such as the extent of bony resection, rehabilitation protocols, and duration of preoperative symptoms.³⁹ Overall, controlled studies converge on the conclusion that postoperative pain improvements are substantial for both techniques and broadly comparable when assessed side by side.

Adverse events were infrequent and similar between techniques in our analysis, although paresthesia and scar tenderness appeared more often in open cases. Restuccia et al⁴⁰ described sural nerve neuromas following lateral open approaches, highlighting the vulnerability of neural structures in open resection. Endoscopic approaches inherently avoid extensive incisional trauma and appear to result in fewer sensory disturbances and less scar-related morbidity.⁴¹ However, the overall low frequency of complications in both groups limits statistical power to detect differences, and larger controlled studies with standardized complication reporting are needed to draw definitive conclusions.

Study limitations

This study has several limitations that should be acknowledged. All included studies were observational and rated as having a serious overall risk of bias, which weakens causal inference.

A central limitation of this review is that the functional and pain outcomes available in the comparative literature rely on instruments with recognized psychometric shortcomings. The AOFAS Clinical Rating Systems are not considered valid or reliable by contemporary standards, as reflected in official AOFAS position statements, which constrains the strength of inferences drawn from AOFAS-based outcomes.^32,33 In addition, although VISA-A is a widely used PROM, recent evidence has raised concerns regarding its psychometric structure, thereby reducing the precision of conclusions based solely on this instrument.³⁴ Accordingly, conclusions related to function and pain relief should be viewed as a critical synthesis of the available evidence and interpreted considering the measurement limitations of the instruments used in the primary studies.^32-34

In addition, sample sizes were relatively small, and only a few studies contributed data for certain outcomes. Postoperative pain was reported in only 2 studies, and operative time in 3 studies, which reduced statistical power and precision to detect clinically relevant differences and to explore heterogeneity. Moreover, the included cohorts were not fully homogeneous in the underlying diagnosis (Haglund deformity vs insertional Achilles tendinopathy), which may limit comparability and the generalizability of pooled estimates across these related but distinct entities.

On the other hand, several methodologic strategies were adopted to mitigate these limitations. We restricted inclusion to controlled comparative studies, systematically assessed risk of bias using the ROBINS-I tool, and applied a random effects model, prediction intervals, leave-one-out sensitivity analyses, and exploratory meta-regressions in the statistical synthesis. Although the overall certainty of the evidence remains low, our results offer a conservative and methodologically robust synthesis of the best comparative data currently available on open and endoscopic techniques for HD.

Conclusion

This meta-analysis did not identify consistent differences between endoscopic and open surgery for Haglund deformity regarding postoperative ankle function, pain, or adverse events. Operative time tended to be shorter in open procedures, but this finding was highly heterogeneous and not robust in sensitivity analyses. Overall, the available comparative evidence is sparse, at serious risk of bias, and imprecise; moreover, inferences about pain and function are further constrained by the measurement properties of the outcome instruments used in the source studies. Therefore, the current evidence does not support a definitive claim of superiority, equivalence, or noninferiority for either technique. These results should be interpreted as a conservative synthesis of the currently available comparative evidence and underscore the need for adequately powered randomized clinical trials using standardized, validated outcome measures to guide surgical decision making.

Supplemental Material

sj-pdf-1-fao-10.1177_24730114261435962 – Supplemental material for Open vs Endoscopic Surgical Treatment for Haglund Deformity: A Systematic Review, Meta-analysis, and Meta-regression

Supplemental material, sj-pdf-1-fao-10.1177_24730114261435962 for Open vs Endoscopic Surgical Treatment for Haglund Deformity: A Systematic Review, Meta-analysis, and Meta-regression by Alex Guedes, Enilton de Santana Ribeiro de Mattos, Eduardo Silva Reis Barreto and César Romero Antunes Júnior in Foot & Ankle Orthopaedics

Footnotes

Supplementary Material

Acknowledgements

The authors have no acknowledgments to declare.

ORCID iDs

Eduardo Silva Reis Barreto, MDc

César Romero Antunes Júnior, MDc

Ethical Considerations

Not applicable.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Disclosure forms for all authors are available online.

Data Availability Statement

All data generated or analyzed during this study are included in this article and its supplementary materials.

Use of Artificial Intelligence (AI) Tools

Artificial intelligence tools (ChatGPT, OpenAI) and automated grammar-checking software (Grammarly, Grammarly Inc.) were used exclusively for linguistic revision of the manuscript. The organization of the text, as well as all content, analyses, and interpretations, were entirely produced and approved by the authors, who take full responsibility for the final version. No AI tools were used for searching, generating, or verifying references. All references were manually retrieved and validated by the authors using international scientific databases, ensuring that no artificial or non-existent citations are included.

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