2.2.1

Patients were positioned in the lateral decubitus position with the operative leg on an elevated bone foam over a radiolucent table, and a thigh tourniquet was applied. The non-operative leg was flexed out of the surgical field. Under fluoroscopic guidance, a Kirschner wire was used to mark the trajectory for a 10 mm dorsal closing wedge osteotomy on the lateral calcaneus ( Fig. 2 A).

(A) Intraoperative fluoroscopic image of K-wire used to plan osteotomy trajectory. (B) K wire marking on skin of planned osteotomy trajectory and high-speed burr inserted through percutaneous incision.

A 5 mm incision was made at the apex of the osteotomy over the lateral calcaneus, 5–8 mm from the plantar cortex, just anterior to the calcaneal tuberosity. Blunt dissection to the bone was performed using a straight haemostat. A 3.1 mm calcaneal wedge burr was advanced into the lateral calcaneus to create a V-shaped dorsal closing wedge osteotomy ( Fig. 2 B). Continuous saline irrigation was used with burring, paused every 10–15 s for cooling and cleaning.

The ankle was dorsiflexed to close the osteotomy and temporarily stabilized with two vertically stacked guidewires under fluoroscopy. Two 6.5 mm headless compression screws (HCS) were inserted across the osteotomy site with the ankle in maximal dorsiflexion, and implant position was confirmed fluoroscopically ( Fig. 3 A and B).

(A) Surgeon maximally dorsiflexing the ankle to close the osteotomy gap (B) Two 6.5 mm headless compression screws inserted to compress the osteotomy site.

2.2.2

Patients were positioned prone on a radiolucent table with a thigh tourniquet applied. A longitudinal midline skin incision was made, and the Achilles tendon was centrally split and partially detached from the calcaneus, preserving the medial and lateral tendon attachments to maintain tension.

The diseased tendon was debrided, the retrocalcaneal bursa excised, and the Haglund’s prominence was resected using an oscillating saw and rongeurs as shown in Fig. 4 .

Midline tendon splitting approach with visualized calcaneum. Haglund deformity in this patient was already excised with oscillating saw.

The Achilles tendon was then reattached to the posterior calcaneus using two suture anchors with the foot in a plantigrade position ( Fig. 5 ).

Reattached Achilles tendon into the calcaneum using suture anchors.

2.2.3

Skin closure was standardized for both groups using non-absorbable synthetic sutures. All patients received firm bandaging postoperatively and three doses of intravenous antibiotics, per institutional protocol.

2.3.1

Postoperatively, patients were fitted with a Darco shoe and allowed toe-touch to partial weight-bearing with ankle range-of-motion (ROM) exercises during the first 2 weeks. Progressive weight-bearing in a controlled ankle movement (CAM) boot was initiated after and gradually weaned off. Open-chain lower-limb exercises were permitted during the first 6 weeks, followed by closed-chain exercises under the supervision of physiotherapy. High-impact and strenuous activities were avoided for 3 months, with a gradual return thereafter.

2.3.2

Patients were immobilized for the first 2 weeks in an above-the-ankle plaster cast with the foot in a plantigrade position and non-weight-bearing to protect the Achilles tendon reattachment. After cast removal, they transitioned to a CAM boot with heel wedges, which are gradually removed over the next 4 weeks. This is followed by progressive strengthening under the guidance of a physiotherapist, which includes Achilles tendon stretching, ankle ROM, and proprioception exercises.