Haglund deformity surgery: bump removal and heel bone procedures

When surgery is considered

For background on the condition, see Haglund deformity. Non-surgical care comes first: anti-inflammatory medicine, ice, stretching, heel lifts or pads, softer or open-backed shoes, physical therapy and, occasionally, casting.^[3] Surgery is considered when a well-tried program has not given enough relief and symptoms are limiting your daily life.^[1,3]

The main types of operation

Surgery typically has three parts. The surgeon removes the inflamed bursa behind the heel, shaves down the prominent corner of the heel bone (calcaneoplasty), and cleans up any diseased tendon where the Achilles attaches.^[1] The approaches are:

• Open surgery. The bump is removed through an incision at the back or side of the heel. It gives the surgeon a direct view, and it may be chosen when the tendon needs more work.
• Endoscopic surgery. The bone is trimmed through two small incisions with a camera and small instruments. It avoids a large incision over the back of the heel.^[1,2]
• Heel bone osteotomy (Zadek osteotomy). A cut in the heel bone is used to change its angle, so that the prominent corner no longer presses on the tendon. It is another option for insertional Achilles tendinopathy that has not settled with other treatment.^[6]

If the Achilles tendon has been detached or damaged at its attachment, it may need to be repaired or reinforced. See Achilles tendon repair and Achilles tendon injuries.

What do the results show?

• Open versus endoscopic. A systematic review of 35 studies (1,260 ankles) found good results and high satisfaction overall. Endoscopic surgery had a higher average function score (about 91 versus 87 out of 100). It also had a lower complication rate (about 4% versus 15%) and a lower failure rate (about 1% versus 6%). Return to daily activities was faster (about six versus 17 weeks on average).^[2] A meta-analysis of 39 studies of insertional Achilles tendinopathy, a related heel problem, found similar function scores with both approaches, and again fewer complications and faster recovery with endoscopic surgery.^[4] Another review of 20 studies also found both approaches effective, with shorter operations and better cosmetic results with endoscopy.^[1] These are comparisons across studies rather than direct trials, and the authors call for further research.
• Zadek osteotomy. Across eight case series (247 patients), function scores rose from about 56 to 93 out of 100. Most complications were minor: symptomatic hardware (about 3%), numbness or tingling from irritation of the sural nerve (2%) and superficial infection (3%). Nonunion occurred in about 1% and deep vein thrombosis in about 1%.^[6]

Recovery

Recovery depends on the operation and on whether the tendon needed repair. After endoscopic surgery, people in the reviews returned to daily activities after six to seven weeks on average. After open surgery it took 17 to 22 weeks. Return to sport took about 12 weeks after endoscopic surgery and 21 to 22 weeks after open surgery.^[2,4] These averages come from many different studies and surgeons, and your own timetable may differ. A typical plan is a period in a boot or cast, gradual weight-bearing, and physical therapy to restore strength and flexibility. See recovery after foot and ankle surgery and preparing for foot and ankle surgery.

Risks

Complications are uncommon, and wound-healing problems are the most common.^[5] Other risks include infection, numbness or irritation of the sural nerve, ongoing pain, stiffness, a persistent bump, weakness or injury of the tendon, and the general risks of surgery, including blood clots. The chance of these depends on the operation and on your health, including diabetes and smoking, so tell your surgeon about them.

Questions to ask before deciding

• Have I done enough non-surgical treatment, and are there any other options?
• Would you recommend open surgery, endoscopy or an osteotomy for my heel?
• Will the Achilles tendon need to be repaired, and how does that change recovery?
• When can I walk on the foot, wear regular shoes, drive and return to work and sport?

When to seek care