跟腱末端病的诊断及手术治疗

目的探讨跟腱末端病的诊断及手术治疗效果。方法18例20足跟腱末端病患者，男10例11足，女8例9足；年龄18-45岁，平均25．7岁。发病至手术时间6-25个月，平均8．3个月；撞击试验阳性12足，可疑阳性5足，阴性3足；局封试验阳性18足，阴性2足。患者术前均摄X线片，测量Fowler和Philip角（Fowler and Philip angle，FPA）、Steffensen和Evensen角（Steffensen and Evensen ansle，SEA）、后跟全角（posterior heel total angle，PHTA）、Chauveaux-Liet角（Chauveaux-Liet angle，CLA），并与文献报道的正常值比较。患者平卧，取跟腱止点处外侧切口，切除跟腱表面滑囊和跟骨后滑囊组织，同时去除跟腱内的钙化灶。以骨刀去除跟骨后上结节处的骨块，剥离的跟腱经骨隧道缝合固定。术后短腿石膏托固定4-6周。结果FPA 7足≥75°，19足≥65°；SEA 14足≥63°；PHTA 7足≥89°；CLA 15足≥10°。经12-78个月（平均25-3个月）的随访，优11足，良6足，可3足，优良率为85％。X线检查未见跟腱周围新生骨形成。结论X线测量仅能作为评估跟骨畸形的一种辅助手段。对保守治疗无效的患者应进行手术治疗。术中只有同时处理跟腱病变和骨性畸形，解除撞击，才能获得良好的临床效果。     

手术治疗Haglund综合征17例

目的:观察手术切除跟骨结节及跟腱钙化灶并用铆钉固定跟腱止点治疗Haglund综合征的疗效。方法:对17例经保守治疗无效的Haglund综合征患者采用手术切除跟骨结节及跟腱钙化灶并用铆钉固定跟腱止点治疗。术后复查相关影像学资料,采用AOFAS踝-后足功能评分标准对患足踝功能进行评估。结果:所有患者切口均一期愈合,随访时间为7~21个月,平均15.8个月,末次随访见患足踝关节主被动活动均正常,无足踝部皮肤感觉减弱等相关后遗症发生。随访AOFAS功能评分为81~98分,平均87.6分。优15足,良4足,可2足,优良率为90.48%。影像学资料提示跟腱愈合良好,周围无炎性反应、水肿及骨质增生。结论:对保守治疗3~6个月无效或效果不佳的Haglund综合征患者采用手术切除跟骨结节及跟腱钙化灶并用铆钉固定跟腱止点,操作简单,术后功能恢复满意。     

改良小L形入路距下关节撑开植骨融合治疗陈旧性跟骨骨折距下关节炎

目的：观察改良跟腱旁后外侧小“L”入路距下关节撑开植骨融合治疗陈旧性跟骨骨折距下关节炎的疗效。方法：2009年3月至2012年9月,应用改良小“L”入路距下关节撑开植骨融合术治疗22例跟骨骨折伴距下关节炎患者,男13例,女9例;年龄22～49岁,平均35．3岁。病程11～32个月,平均21个月。根据Stephens-Sanders分型,Ⅱ型16例,Ⅲ型6例。通过改良AOFAS踝与后足评分标准对手术前后患足功能进行评估,比较改善程度。结果：1例出现皮缘坏死,无感染、螺钉断裂、植骨吸收及距骨坏死等情况发生。术后21例获随访,时间18～46个月,平均29个月。术后4个月融合处均获骨性愈合。末次随访时改良AOFAS评分由术前32-65分（平均50．8分）提高至末次随访66～92分（平均82．6分）,与术前比较差异有统计学意义（P〈0.01）。结论：改良小“L”入路距下关节撑开植骨融合术是治疗陈旧性跟骨骨折并发距下关节炎的一种有效方法,临床操作简单,并发症少,可矫正跟骨骨折畸形愈合的主要病理改变,恢复足部外形并改善后足功能。     

Haglund病的手术治疗体会

背景：目前在Haglund病的治疗中，手术治疗指征及方法尚存在争议。目的：探讨应用带线锚钉重建跟腱止点治疗Haglund病的临床效果。方法：2009年1月至2013年11月我院收治Haglund病患者15例，其中男10例，女5例；年龄37~58岁，平均42.5岁。采用锚钉重建跟腱止点。术后进行临床及影像学随访，采用AOFAS踝-后足功能评分标准进行足踝部功能评估。结果：所有患者伤口均一期愈合，无皮肤坏死和切口周围麻木。术后随访6~22个月，平均15.8个月，末次随访AOFAS踝-后足功能评分为71~93分（平均83.6分）。其中优10足，良3足，可2足，优良率为86.7%。X线检查未见跟腱周围新生骨增生，MR提示跟腱愈合良好。结论：在严格掌握手术适应证的前提下，采用锚钉重建跟腱止点治疗Haglund病，手术操作简单，疗效确切，并发症少。但远期临床疗效仍需进一步观察。     

硬膜外穿刺针辅助穿线经跟骨骨隧道治疗跟腱断裂

目的 探讨通过硬膜外穿刺针辅助穿线经跟骨骨隧道治疗跟腱断裂的临床疗效。方法 回顾性分析2017年1月-2021年1月应用硬膜外穿刺针经跟骨骨隧道引导缝线加固止点治疗的22例跟腱断裂病例。急性闭合跟腱断裂患者的切口于跟腱断裂皮肤空虚处上缘行2～3 cm横行小切口,二次跟腱断裂患者取原切口或后内侧纵行切口。通过硬膜穿刺针分别在跟腱断裂近端、远端及跟骨处建立辅助隧道,引导穿入跟腱缝合线,结合改良Bunnell缝合法将断裂跟腱缝合。结果 随访22例,随访时间9～14个月。术后切口全部一期愈合,无深部感染、肌腱粘连、二次断裂、腓肠神经激惹等严重并发症发生。术后9个月踝关节活动度：跖屈25°～45°,背伸15°～25°,美国矫形足踝协会踝与后足评分平均93(85～97)分,优16例,良6例,优良率100%;Amer-Lindholm疗效评价标准评价：优18例,良4例,优良率100%;恢复至伤前体育活动水平19例（86.3%）,重返运动时间19～24周,平均21.6周。结论 采用硬膜外穿刺针经跟骨骨隧道引导缝线加固止点跟腱断裂,临床效果确切,并发症少,器材易得,操作简单,值得临床尤其是基层医院推广。     

跟骨丘部及后距下关节重建治疗跟骨骨折畸形

目的探讨保留距下关节跟骨丘部及后距下关节重建治疗严重陈旧性跟骨骨折畸形愈合的方法及适应证。方法跟骨丘部及后距下关节重建治疗严重陈旧性跟骨骨折畸形愈合8例，均为男性，年龄在21～34岁，平均31．5岁。单侧7例，双侧1例。损伤时间1～7个月，平均4．6个月。行重建丘部及后距下关节保留距下关节自体植骨的方法进行治疗，切除跟骨外膨的外侧壁，取跟骨外侧壁植骨7例，取髂骨植骨1例。结果8例9足获得随访，随访时间8～24个月，平均11个月。按美国足踝外科协会Maryland足部评分系统评价术后功能：优4足，良4足，可1足，差0足，优良率为88．9％。所有患者术后足外形恢复良好。术后切口感染裂开1例、螺钉断裂1例，无跟骨内翻等并发症。骨折愈合时间10．5～16．2周，平均12．6周。术后X线片显示跟骨丘部高度、宽度、BoNer角，以及Gissane角基本恢复正常。结论重建跟骨丘部及距下关节自体植骨术具有矫正跟骨畸形，恢复后足外形及功能明显的优点，是治疗严重陈旧性跟骨骨折畸形愈合的有效方法。     

跟腱断裂合并跟腱末端病变的手术治疗

[目的]介绍跟骨结节切除带线铆钉止点重建术治疗跟腱断裂合并跟腱末端病变的手术技术。[方法]7例跟腱断裂合并跟腱末端病变患者采用跟骨结节及变性跟腱切除、带线铆钉止点重建术。术中切除足够大的跟骨骨块,切除变性坏死跟腱,对于缺损较小者(2 cm)直接行带线铆钉缝合固定于跟骨,缺损较大者(2 cm)采取腓肠肌腱V-Y延长技术及自体肌腱移植来恢复跟腱长度和维持后期踝关节功能。延长跟腱,带线铆钉跟腱止点重建,术后石膏固定4周。[结果]术后1例切口出现红肿,经伤口换药、升级抗生素后愈合。7例获6个月~2年随访,采用Arner-Lindholm评分标准,临床结果评定为优6足,良1足。所有患者踝关节背伸跖屈功能正常。[结论]跟骨结节及变性跟腱切除、带线铆钉止点重建术治疗跟腱断裂合并跟腱末端病具有较好的临床疗效,术中细致操作、足够大的骨块切除、变性坏死跟腱的切除、带线铆钉止点重建等是手术成功的关键。     

微创截骨手法整复术治疗小趾囊炎

目的：研究微创截骨手法整复术治疗小趾囊炎的疗效。方法：2003年7月至2008年6月,小趾囊炎患者90例（160足）,男3例（5足）,女87例（155足）;年龄17～76岁,平均49．2岁;病史1-32年,平均10．1年。采用微创截骨手法整复术治疗和改良Coughlin疗效标准进行评价。结果：本组术后均获随访,时间3-36个月,平均15．7个月。根据改良Coughlin疗效标准,优80例,良8例,可2例,差0例,优良率为97．8％。2例出现延迟愈合,延长固定时间后截骨端愈合。结论：微创截骨手法整复术治疗小趾囊炎方法简便易行,疗效确切。     

解剖接骨板治疗SandersⅡ～Ⅳ型跟骨骨折的临床疗效

目的评价解剖接骨板治疗SandersⅡ～Ⅳ型跟骨骨折的临床疗效。方法2008年9月至2010年10月行解剖接骨板内固定治疗并获得随访的SandersⅡ-Ⅳ型跟骨骨折29例（33足）,男19例,女10例;年龄18—58岁,平均37岁。双侧跟骨骨折4例,合并骨盆骨折3例,合并胸腰段压缩性骨折3例;闭合性跟骨骨折27例,开放性跟骨骨折2例;术前根据影像学检查分为SandersⅡ型16例（16足）,SandersⅢ型9例（11足）,SandersⅣ型4例（6足）。按照Maryland Foot Score标准进行患足功能评价。结果29例（33足）获得随访,随访时间为9—21个月,平均11．3个月。跟骨骨折达骨性愈合时间为2—4个月,平均2．9个月;患足完全负重时间为2．5—4个月,平均3．2个月;无一例发生延迟愈合及不愈合。闭合性跟骨骨折术前准备时间为5～12天,平均8天。术后2例（2足）出现切口边缘皮肤坏死。2例开放性跟骨骨折患者中1例（1足）因软组织损伤严重,最终行局部旋转皮瓣植皮术治疗。术后患足Bohler角及Gissane角均得到显著改善（P〈0．05）。SandersⅡ型优良率为87．5％,SandersⅢ型优良率为81．8％,SandersⅣ型优良率为50％。结论切开复位解剖接骨板内固定术是治疗SandersⅡ～Ⅳ型跟骨骨折的有效方法。     

婴幼儿先天性垂直距骨手术治疗体会

目的探讨先天性垂直距骨的手术方法及疗效.方法自2000年4月～2003年3月共手术治疗6例10足先天性垂直距骨,女4例,男2例;神经肌肉型(Ⅱ型)4足,错构综合征型(Ⅲ型)5足,特发型1足.手术时年龄为13～39个月,平均16.5个月.采用足后与足背双切口行一期软组织松解手术跟腱内侧纵切口内延长跟腱,切开踝、距下关节囊.足背踝关节前下方切口(从腓骨小头下方至距舟关节外侧)内切断第三腓骨肌,延长趾长伸肌和腓骨长短肌;松解跟骰、距下以及距舟关节等关节囊;胫前肌止点穿越距骨颈.距舟关节复位后用两枚克氏针分别固定距舟关节和跟距关节.术后踝跖屈石膏固定3个月,然后穿矫形鞋至少12个月.结果6例患者随访时间6～33个月,平均23.1个月.以Adelaar的临床指标和足侧位片测得的距骨轴-第一跖骨基底部夹角(TAMBA),跟骨轴-第一跖骨基底部夹角(CAMBA)为评判标准.术后10足均保持良好外观和足弓,足底无距骨头突出,距下关节和踝关节无明显功能障碍,2足于负重位有轻度跟外翻,7足还未脱离矫形鞋.X线片示无距骨缺血性坏死.平均TAMBA术前66°(50°～98°),随访末期为1.6°(-11°～16°).平均CAMBA术前26.1°(14°～60°),随访末期为-5.45°(-13°～3°).结论手术复位是治疗先天性垂直距骨的惟一方法,单纯软组织松解术是婴幼儿患者的最佳选择.     

Endoscopic bony and soft-tissue decompression of the retrocalcaneal space for the treatment of Haglund deformity and retrocalcaneal bursitis

BACKGROUND: The traditional operative management of Haglund deformity and retrocalcaneal bursitis consists of an open excision of the inflamed bursa, resection of the posterosuperior calcaneal tuberosity, and debridement of the Achilles tendinopathy. In an effort to reduce morbidity and recovery time, an endoscopic technique was used for the management of this condition. METHODS: Thirty consecutive patients (32 heels) who had retrocalcaneal bursitis unrelieved by nonoperative measures were treated with the endoscopic technique. Two portals were created, one laterally and one medially, over the posterosuperior portion of the calcaneus to gain access to the retrocalcaneal space. The inflamed bursal tissue was removed, and the prominent bone was resected. Patients were evaluated preoperatively and postoperatively with the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Scale. RESULTS: The mean followup was 35 months. Twenty-eight patients (30 heels) were available for followup. The AOFAS scores averaged 62 preoperatively and 97 postoperatively. There were 26 excellent results, three good results and one poor result. One major and one minor complication occurred: an Achilles tendon rupture three weeks after surgery and residual pain and swelling that required reoperation through an open procedure. There were no wound complications or postoperative infections. CONCLUSIONS: The endoscopic technique can be done outpatient and has a low morbidity and high patient satisfaction. The time to return to normal activity level is short. Sufficient exposure of the Achilles tendon and removal of the calcaneal prominence and retrocalcaneal bursa can be done effectively using an endoscopic technique.     

Technique and results of Achilles tendon detachment and reconstruction for insertional Achilles tendinosis

BACKGROUND: Insertional Achilles tendinosis is a clinical entity that commonly occurs with other posterior heel disorders such as retrocalcaneal bursitis, Haglund deformity, intratendinous ossification and pretendinous bursitis. Complete detachment and reconstruction of the Achilles tendon was evaluated as a method of treatment for this condition. METHODS: Seventy-five patients (81 heels) were treated over a 5-year period for chronic insertional Achilles tendinosis. These were divided in two groups: a nondetached group (26 patients, 31 heels, average age 55 years) included all patients with debridement of the Achilles tendon with no or partial detachment of the tendon, and a detached group (49 patients, 50 heels, average age 56.1 years) that included all patients with complete detachment, debridement, and reattachment with suture anchors of the Achilles tendon associated with proximal V-Y lengthening of the proximal aponeurosis. Sixty-one patients (65 heels) were contacted for an interview questionnaire, 22 patients from the nondetached group (26 heels) and 39 patients from the detached group (39 heels). The average followup for the nondetached group was 47 months and for the detached group 33 months. Items evaluated included pain, activity limitation, gait change, walking distance, return to sport or work, and level of satisfaction. RESULTS: No statistically significant differences were noted in relation to any of the items evaluated. In the nondetached group, the satisfaction rate was 92%, and 8% were dissatisfied. In the detached group, 74% were completely satisfied and 18% were satisfied with reservations. Eight percent were dissatisfied. Complications included minor wound dehiscence (one in the nondetached, five in the detached group), wound infection (one in the nondetached group, two in the detached group) and sural neuritis (two in the detached group). CONCLUSIONS: Complete detachment of the Achilles tendon and reattachment with suture anchors and a proximal V-Y lengthening was a reliable and effective method of treatment for severe chronic insertional Achilles tendinosis as was debridement of the tendon insertion without detachment for less severe involvement.     

Can local corticosteroid injection in the retrocalcaneal bursa lead to rupture of the Achilles tendon and the medial head of the gastrocnemius muscle?

Purpose

The purpose of the study is to explain the cause–effect relationship in three patients who reported combined ruptures of the Achilles tendon and the gastrosoleus complex 6 months after they had received corticosteroids injections for the management of retrocalcaneal bursitis.

Methods

Three cryopreserved cadavers (three men, three left legs) were examined to assess the anatomic connection between the retrocalcaneal bursa and the Achilles tendon (distal and anterior fibers). Blue triptan medium contrast was injected.

Results

An unexpected connection between the retrocalcaneal bursa and the anterior fibers of the Achilles tendon was found in all instances.

Conclusions

Local corticosteroid injection of the retrocalcaneal bursa may help the symptoms of retrocalcanear bursitis, but pose a risk of Achilles tendon rupture. This risk–benefit has to be taken into account when corticosteroid injections are prescribed to professional and high-level athletes.     

Appearance of the weight-bearing lateral radiograph in retrocalcaneal bursitis

Background and purpose A retrocalcaneal bursitis is caused by repetitive impingement of the bursa between the Achilles tendon and the posterosuperior calcaneus. The bursa is situated in the posteroinferior corner of Kager's triangle (retrocalcaneal recess), which is a radiolucency with sharp borders on the lateral radiograph of the ankle. If there is inflammation, the fluid-filled bursa is less radiolucent, making it difficult to delineate the retrocalcaneal recess. We assessed whether the radiographic appearance of the retrocalcaneal recess on plain digital (filmless) radiographs could be used in the diagnosis of a retrocalcaneal bursitis.

Methods Whether or not there was obliteration of the retrocalcaneal recess (yes/no) on 74 digital weight-bearing lateral radiographs of the ankle was independently assessed by 2 observers. The radiographs were from 24 patients (25 heels) with retrocalcaneal bursitis (confirmed on endoscopic calcaneoplasty); the control group consisted of 50 patients (59 heels).

Results The sensitivity of the test was 83% for observer 1 and 79% for observer 2. Specificity was 100% and 98%, respectively. The kappa value of the interobserver reliability test was 0.86. For observer 1, intraobserver reliability was 0.96 and for observer 2 it was 0.92.

Interpretation On digital weight-bearing lateral radiographs of a retrocalcaneal bursitis, the retrocalcaneal recess has a typical appearance.     

Appearance of the weight-bearing lateral radiograph in retrocalcaneal bursitis

Background and purpose

A retrocalcaneal bursitis is caused by repetitive impingement of the bursa between the Achilles tendon and the posterosuperior calcaneus. The bursa is situated in the posteroinferior corner of Kager''s triangle (retrocalcaneal recess), which is a radiolucency with sharp borders on the lateral radiograph of the ankle. If there is inflammation, the fluid-filled bursa is less radiolucent, making it difficult to delineate the retrocalcaneal recess. We assessed whether the radiographic appearance of the retrocalcaneal recess on plain digital (filmless) radiographs could be used in the diagnosis of a retrocalcaneal bursitis.

Methods

Whether or not there was obliteration of the retrocalcaneal recess (yes/no) on 74 digital weight-bearing lateral radiographs of the ankle was independently assessed by 2 observers. The radiographs were from 24 patients (25 heels) with retrocalcaneal bursitis (confirmed on endoscopic calcaneoplasty); the control group consisted of 50 patients (59 heels).

Results

The sensitivity of the test was 83% for observer 1 and 79% for observer 2. Specificity was 100% and 98%, respectively. The kappa value of the interobserver reliability test was 0.86. For observer 1, intraobserver reliability was 0.96 and for observer 2 it was 0.92.

Interpretation

On digital weight-bearing lateral radiographs of a retrocalcaneal bursitis, the retrocalcaneal recess has a typical appearance.     

Outcome of endoscopic decompression of retrocalcaneal bursitis

Background:

Posterior heel pain due to retrocalcaneal bursitis, is a disabling condition that responds well to the conventional methods of treatment. Patients who do not respond to conservative treatment may require surgical intervention. This study evaluates the outcome of endoscopic decompression of retrocalcaneal bursitis, with resection of posterosuperior eminence of the calcaneum.

Materials and Methods:

This present study included 25 heels from 23 consecutive patients with posterior heel pain, who did not respond to conservative treatment and underwent endoscopic decompression of the retrocalcaneal bursae and excision of bony spurs. The functional outcome was evaluated by comparing the pre and postoperative American Orthopedic Foot and Ankle Society (AOFAS) scores. The Maryland ankle and foot score was used postoperatively to assess the patient''s satisfaction at the one-year followup.

Results:

The University of Maryland scores of 25 heels were categorized as the nonparametric categories, and it was observed that 16 patients had an excellent outcome, six good, three fair and there were no poor results. The AOFAS scores averaged 57.92 ± 6.224 points preoperatively and 89.08 ± 5.267 points postoperatively (P < 0.001), at an average followup of 16.4 months. The 12 heels having noninsertional tendinosis on ultrasound had low AOFAS scores compared to 13 heels having retrocalcaneal bursitis alone. At one year followup, correlation for preoperative ultrasound assessment of tendoachilles degeneration versus postoperative Maryland score (Spearman correlation) had shown a strong negative correlation.

Conclusion:

Endoscopic calcaneal resection is highly effective in patients with mild or no degeneration and yields cosmetically better results with fewer complications. Patients with degenerative changes in Achilles tendon had poorer outcomes in terms of subjective satisfaction.     

Achilles tendon reattachment after surgical treatment of insertional tendinosis using the suture bridge technique: a case series

Achilles tendinopathy is a clinical diagnosis characterized as a triad of symptoms including pain, swelling, and impaired performance of the diseased tendon. Achilles tendinopathy is divided into Achilles tendonitis and tendinosis based on histopathological examination. Achilles tendinosis is viewed microscopically as disorganized collagen, abnormal neovascularization, necrosis, and mucoid degeneration. Insertional Achilles tendinosis is a degenerative process of the tendon at the junction of the tendon and calcaneus. This disease is initially treated conservatively with activity modification, custom orthotic devices, heel lifts, and immobilization. After 3 to 6 months of conservative therapy has failed to alleviate symptoms, surgical management is indicated. Surgical management of insertional Achilles tendinosis includes Achilles tendon debridement, calcaneal exostosis ostectomy, and retrocalcaneal bursa excision. In this case series, we present 4 patients who underwent surgical management of insertional Achilles tendinosis with complete tendon detachment. All patients underwent reattachment of the Achilles tendon with the suture bridge technique. The Arthrex SutureBridge^® (Arthrex, Inc., Naples, FL) device uses a series of 4 suture anchors and FiberWire^® (Arthrex Inc.) to reattach the Achilles tendon to its calcaneal insertion. This hourglass pattern of FiberWire^® provides a greater area of tendon compression, consequently allowing greater stability and possible earlier return to weightbearing activities. The patients were followed up for approximately 2 years’ duration. There were no intraoperative or postoperative complications. At final follow-up there was no evidence of Achilles tendon ruptures or device failures. All patients were able to return to their activities of daily living without the use of assistive devices. The patients’ average visual analog pain scale was 1 (range 0 to 4), and their average foot functional index score was 3.41 (range 0 to 10.71). The suture bridge technique is a viable option for Achilles tendon repair after surgical management of insertional Achilles tendinosis.     

Surgical Correction of Haglund's Triad Using a Central Tendon-Splitting Approach: A Retrospective Outcomes Study

We evaluated the surgical outcomes of Haglund's triad using a central tendon-splitting approach, with Achilles tendon partial detachment and debridement, excision of the retrocalcaneal bursa, resection of Haglund's prominence, and reattachment of the Achilles tendon. The medical records of 22 patients (22 heels) who had undergone surgical correction of Haglund's triad from January 2010 to December 2015 were reviewed retrospectively. The visual analog scale pain score, American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot scale score, and 36-item Short-Form Health Survey physical and mental component scores were prospectively collected preoperatively, 6 months postoperatively, and at the last visit. The scores of a subjective question involving satisfaction were prospectively collected at the last visit. Possible risk factors were also evaluated. We reviewed the data from 12 females and 10 males, with the mean age of 59.2 ± 7.3 years and a mean follow-up duration of 15.1 ± 4.6 months. Significant improvement was found in the mean visual analog scale pain score, average American Orthopaedic Foot and Ankle Society Ankle-Hindfoot scale score, and 36-item Short-Form Health Survey physical component scale score. The overall satisfaction rate was 77.3% (17 of 22). Postoperative complications included 2 cases of delayed wound healing and 1 case of sensation loss over the heel wound. No Achilles tendon rupture or wound infection developed. Gender and body mass index did not affect the surgical outcomes. The surgical technique we used for Haglund's triad provided effective pain relief, function improvement, and overall enhancement of patients' health condition. More research is required to further evaluate the outcomes of our surgical approach to treat Haglund's triad and the possible risk factors.     

Four common types of bursitis: diagnosis and management

Bursitis is a common cause of musculoskeletal pain and often prompts orthopaedic consultation. Bursitis must be distinguished from arthritis, fracture, tendinitis, and nerve pathology. Common types of bursitis include prepatellar, olecranon, trochanteric, and retrocalcaneal. Most patients respond to nonsurgical management, including ice, activity modification, and nonsteroidal anti-inflammatory drugs. In cases of septic bursitis, oral antibiotics may be administered. Local corticosteroid injection may be used in the management of prepatellar and olecranon bursitis; however, steroid injection into the retrocalcaneal bursa may adversely affect the biomechanical properties of the Achilles tendon. Surgical intervention may be required for recalcitrant bursitis, such as refractory trochanteric bursitis.     

Insertional Achilles tendinosis: surgical treatment through a central tendon splitting approach

Twenty-two heels in 21 patients treated surgically for a primary diagnosis of insertional Achilles tendinosis were reviewed on the basis of preoperative and postoperative examinations, office records, and a comprehensive questionnaire administered to each subject. Each patient underwent surgical treatment using a midline-posterior skin incision combined with a central tendon splitting approach for debridement, retrocalcaneal bursectomy, and removal of the calcaneal bursal projection as necessary. The findings at surgery revealed involvement of the middle third of the insertion in 21 of 22 cases with only one patient manifesting isolated lateral involvement. Thirteen of 22 had an associated prominent calcaneal bursal projection and four of 22 a superficially inflamed bursa. Three patients required reinsertion of the tendo Achilles via drill holes and one underwent augmentation with a plantaris tendon. Operative findings and complications were reported. Eight male and 13 female patients underwent 22 procedures (one case bilaterally) with an average follow-up of 33 months. Preoperative symptoms include presence of symptoms over a range of three months to two years and pain associated with activities of daily living (17 of 22), limitation of regular activities (six of 22), and pain present at rest in six of 22. Postoperatively, 20 of 22 patients were able to return to work or routine activities by three months; only 13 of 22 were completely pain free. Only 13 of 22 also claimed that they were able to return to unlimited activities. Overall, there was an 82% (18 of 22) satisfaction rate with surgery and 77% (17 of 22) stated they would have the surgery again.