Morphological classification of postero-superior protuberance of calcaneus and its relationship with Haglund deformity_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

ZHANG Lei ^1,2 , ZHANG Man ³ , JIANG Lu ⁴ , HUANG Lei ⁵ , WU Yu ⁶ , LENG Rao ³ , SHI Houyin ^1,2 ,  WANG Guoyou ^1,2

1. Department of Orthopedics, the Affiliated Traditional Chinese Medicine Hospital, Southwest Medical University, Luzhou Sichuan, 646000, P. R. China;
2. Center for Orthopedic Disease Research, the Affiliated Traditional Chinese Medicine Hospital, Southwest Medical University, Luzhou Sichuan, 646000, P. R. China;
3. School of Clinical Medicine, Southwest Medical University, Luzhou Sichuan, 646000, P. R. China;
4. College of Integrated Traditional Chinese and Western Medicine, Southwest Medical University, Luzhou Sichuan, 646000, P. R. China;
5. School of Physical Education, Southwest Medical University, Luzhou Sichuan, 646000, P. R. China;
6. Department of Spinal Orthopedics, Dongguan Hospital of Guangzhou University of Chinese Medicine, Dongguan Guangdong, 523000, P. R. China;

Corresponding author：

WANG Guoyou, Email: wangguoyou1981@swmu.edu.cn

Keywords：

Postero-superior protuberance of the calcaneus; morphology; Haglund deformity; X-ray film

DOI：

10.7507/1002-1892.202502021

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Objective To explore the morphological characteristics of the postero-superior protuberance of the calcaneus and to explore its relationship with Haglund malformation. Methods Ankle lateral X-ray films of 391 hospitalized patients between May 2021 and June 2024 were retrospectively collected. The morphological parameters of the postero-superior protuberance of the calcaneus were measured, including the length of the base, the height of the base, and the tip angle of the postero-superior protuberance of the calcaneus, and the morphological types were classified according to the above parameters, including the peak type, the hill type, and the flat type. The related parameters of Haglund malformation were measured, including Fowler-Philipp angle (FPA), calcaneal pith angle (CPA), parallel pitch line (PPL), Chauveaux-Liet angle (CLA), and X/Y ratio (total calcaneal length/length of greater tuberosity of calcaneus). The differences of the morphological parameters of the postero-superior protuberance of the calcaneus and the related indicators of Haglund deformity among the three types and between male and female were compared and analyzed, and the differences of the positive numbers of the related indicators of Haglund deformity among the three types were compared. Results According to the morphological parameters of the postero-superior protuberance of the calcaneus, there were 64 cases of peak type, 245 cases of hill type, and 82 cases of flat type. There was no significant difference in the length of the base of the postero-superior protuberance of the calcaneus, CPA, CLA, and X/Y ratio among the three types (P>0.05). Among the three types, the peak type had the largest FPA and the flat type had the smallest (P<0.05); the peak type had the smallest tip angle of the postero-superior protuberance of the calcaneus and the flat type had the largest (P<0.05); the positive rate of PPL in the hill type was higher than that in the peak type and flat type (P<0.05); the height of the base of the postero-superior protuberance of the calcaneus in the flat type was the smallest (P<0.05). FPA, CPA, CLA, PPL, and X/Y ratio were positive in 2, 42, 172, 142, and 77 patients, respectively. There was no significant difference in the number of positive Haglund deformity markers among the three types (P>0.05). There was no significant difference between male and female patients in the tip angle of the postero-superior protuberance of the calcaneus, the positive rate of FPA, PPL, and X/Y ratio (P>0.05). The length and the height of the base of the postero-superior protuberance of the calcaneus, CPA, and CLA in male patients were significantly higher than those in female patients (P<0.05). Conclusion The postero-superior protuberance of the calcaneus can be divided into three types: the peak type, the hill type, and the flat type. The peak type is more likely to suffer from Haglund deformity, and the male is more likely to suffer from Haglund deformity than female.

1.	常乐, 郑果, 陈万, 等. 130例跟腱止点腱病流行病学特点分析. 创伤外科杂志, 2023, 25(8): 614-621.
2.	Syed TA, Perera A. A proposed staging classification for minimally invasive management of Haglund’s syndrome with percutaneous and endoscopic surgery. Foot Ankle Clin, 2016, 21(3): 641-664.
3.	Pfeffer G, Gonzalez T, Zapf M, et al. Achilles pullout strength after open calcaneoplasty for Haglund’s syndrome. Foot Ankle Int, 2018, 39(8): 966-969.
4.	钟世江, 徐桂军, 赵嘉国. 跖肌腱解剖与生物力学特征及在韧带重建中的应用. 中国修复重建外科杂志, 2024, 38(2): 234-239.
5.	Hall S, Kaplan JRM, Schipper ON, et al. Minimally invasive approaches to Haglund’s deformity and insertional Achilles tendinopathy: A contemporary review. Foot Ankle Int, 2024, 45(6): 664-675.
6.	Matsui T, Kumai T, Kamijo S, et al. Effect of ankle motion and tensile stress at the Achilles tendon on the contact pressure between the Achilles tendon and the calcaneus. J Foot Ankle Surg, 2021, 60(4): 753-756.
7.	Aggouras AN, Chimenti RL, Samuel Flemister A, et al. Impingement in insertional Achilles tendinopathy occurs across a larger range of ankle angles and is associated with increased tendon thickness. Foot Ankle Int, 2022, 43(5): 683-693.
8.	Pargeon M, Tjiattas-Saleski L. Haglund deformity of the posterior heel. J Osteopath Med, 2023, 123(7): 365-366.
9.	鲁圣助, 谈美娟, 孙强, 等. 新型跟腱微创缝合器械修复新鲜闭合性跟腱断裂的临床研究. 中国修复重建外科杂志, 2023, 37(9): 1062-1067.
10.	Lee W, Giro ME, Crymes C. Association of haglund deformity size and insertional Achilles tendinopathy. Foot Ankle Int, 2023, 44(8): 719-726.
11.	Jenko N, Ariyaratne S, Azzopardi C, et al. Radiological angle assessment of Haglund’s deformity: validation on magnetic resonance imaging. Foot (Edinb), 2024, 59: 102096. doi: 10.1016/j.foot.2024.102096.
12.	Flores DV, Goes PK, Damer A, et al. The heel complex: Anatomy, imaging, pathologic conditions, and treatment. Radiographics, 2024, 44(4): e230163. doi: 10.1148/rg.230163.
13.	赖志斌, 朱永展, 钟的桂, 等. 跟骨成形跟腱止点重建治疗Haglund综合征. 中国矫形外科杂志, 2023, 31(14): 1330-1333.
14.	Kumar A, Rastogi S, Haider Y, et al. Morphometric variations of the lateral surface of calcaneus: Can standard plate sizes fit all? J Clin Orthop Trauma, 2020, 13: 156-162.
15.	Tourné Y, Baray AL, Barthélémy R, et al. Contribution of a new radiologic calcaneal measurement to the treatment decision tree in Haglund syndrome. Orthop Traumatol Surg Res, 2018, 104(8): 1215-1219.
16.	Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics, 1977, 33(1): 159-174.
17.	Bulstra GH, van Rheenen TA, Scholtes VA. Can we measure the heel bump? Radiographic evaluation of Haglund’s deformity. J Foot Ankle Surg, 2015, 54(3): 338-340.
18.	Tourne Y, Baray AL, Barthelemy R, et al. 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.
19.	Opdam KTM, Zwiers R, Vroemen J, et al. 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.
20.	Tay AYW, Goh GS, Li Z, et al. Two-year clinical and radiologic outcomes following surgical treatment of insertional Achilles tendinopathy using a central tendon-splitting approach. Foot Ankle Int, 2023, 44(8): 702-709.
21.	Cengiz B, Karaoglu S. 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.
22.	张洋, 赵永杰, 杜瑞, 等. 锁定钢板联合空心螺钉垂直加压治疗SandersⅡ型和Ⅲ型跟骨骨折. 中国修复重建外科杂志, 2024, 38(4): 432-437.
23.	Fathi Mahmoud H, Feisal W, Samir Fahmy F. Satisfactory functional outcome and significant correlation with the length of Haglund’s deformity after endoscopic calcaneoplasty: A minimum 4-year follow-up study. Adv Orthop, 2022, 2022: 7889684. doi: 10.1155/2022/7889684.
24.	Nischal N, Chandra Lalita K, Iyengar KP, et al. Angle of BRINK-a new way to measure Haglund’s deformity. Skeletal Radiol, 2023, 52(2): 193-198.

1. 常乐, 郑果, 陈万, 等. 130例跟腱止点腱病流行病学特点分析. 创伤外科杂志, 2023, 25(8): 614-621.
2. Syed TA, Perera A. A proposed staging classification for minimally invasive management of Haglund’s syndrome with percutaneous and endoscopic surgery. Foot Ankle Clin, 2016, 21(3): 641-664.
3. Pfeffer G, Gonzalez T, Zapf M, et al. Achilles pullout strength after open calcaneoplasty for Haglund’s syndrome. Foot Ankle Int, 2018, 39(8): 966-969.
4. 钟世江, 徐桂军, 赵嘉国. 跖肌腱解剖与生物力学特征及在韧带重建中的应用. 中国修复重建外科杂志, 2024, 38(2): 234-239.
5. Hall S, Kaplan JRM, Schipper ON, et al. Minimally invasive approaches to Haglund’s deformity and insertional Achilles tendinopathy: A contemporary review. Foot Ankle Int, 2024, 45(6): 664-675.
6. Matsui T, Kumai T, Kamijo S, et al. Effect of ankle motion and tensile stress at the Achilles tendon on the contact pressure between the Achilles tendon and the calcaneus. J Foot Ankle Surg, 2021, 60(4): 753-756.
7. Aggouras AN, Chimenti RL, Samuel Flemister A, et al. Impingement in insertional Achilles tendinopathy occurs across a larger range of ankle angles and is associated with increased tendon thickness. Foot Ankle Int, 2022, 43(5): 683-693.
8. Pargeon M, Tjiattas-Saleski L. Haglund deformity of the posterior heel. J Osteopath Med, 2023, 123(7): 365-366.
9. 鲁圣助, 谈美娟, 孙强, 等. 新型跟腱微创缝合器械修复新鲜闭合性跟腱断裂的临床研究. 中国修复重建外科杂志, 2023, 37(9): 1062-1067.
10. Lee W, Giro ME, Crymes C. Association of haglund deformity size and insertional Achilles tendinopathy. Foot Ankle Int, 2023, 44(8): 719-726.
11. Jenko N, Ariyaratne S, Azzopardi C, et al. Radiological angle assessment of Haglund’s deformity: validation on magnetic resonance imaging. Foot (Edinb), 2024, 59: 102096. doi: 10.1016/j.foot.2024.102096.
12. Flores DV, Goes PK, Damer A, et al. The heel complex: Anatomy, imaging, pathologic conditions, and treatment. Radiographics, 2024, 44(4): e230163. doi: 10.1148/rg.230163.
13. 赖志斌, 朱永展, 钟的桂, 等. 跟骨成形跟腱止点重建治疗Haglund综合征. 中国矫形外科杂志, 2023, 31(14): 1330-1333.
14. Kumar A, Rastogi S, Haider Y, et al. Morphometric variations of the lateral surface of calcaneus: Can standard plate sizes fit all? J Clin Orthop Trauma, 2020, 13: 156-162.
15. Tourné Y, Baray AL, Barthélémy R, et al. Contribution of a new radiologic calcaneal measurement to the treatment decision tree in Haglund syndrome. Orthop Traumatol Surg Res, 2018, 104(8): 1215-1219.
16. Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics, 1977, 33(1): 159-174.
17. Bulstra GH, van Rheenen TA, Scholtes VA. Can we measure the heel bump? Radiographic evaluation of Haglund’s deformity. J Foot Ankle Surg, 2015, 54(3): 338-340.
18. Tourne Y, Baray AL, Barthelemy R, et al. 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.
19. Opdam KTM, Zwiers R, Vroemen J, et al. 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.
20. Tay AYW, Goh GS, Li Z, et al. Two-year clinical and radiologic outcomes following surgical treatment of insertional Achilles tendinopathy using a central tendon-splitting approach. Foot Ankle Int, 2023, 44(8): 702-709.
21. Cengiz B, Karaoglu S. 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.
22. 张洋, 赵永杰, 杜瑞, 等. 锁定钢板联合空心螺钉垂直加压治疗SandersⅡ型和Ⅲ型跟骨骨折. 中国修复重建外科杂志, 2024, 38(4): 432-437.
23. Fathi Mahmoud H, Feisal W, Samir Fahmy F. Satisfactory functional outcome and significant correlation with the length of Haglund’s deformity after endoscopic calcaneoplasty: A minimum 4-year follow-up study. Adv Orthop, 2022, 2022: 7889684. doi: 10.1155/2022/7889684.
24. Nischal N, Chandra Lalita K, Iyengar KP, et al. Angle of BRINK-a new way to measure Haglund’s deformity. Skeletal Radiol, 2023, 52(2): 193-198.

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