Calcaneal Avulsion Fractures Research Articles

Analysis of Calcaneal Avulsion Fractures Treated Surgically and Nonsurgically: A Retrospective Multicenter Study.

Calcaneal avulsion fractures (CAvFs) at the Achilles tendon insertion are among the more challenging fractures to treat. Although rare, they often require reoperation. The optimal treatment, including nonsurgical procedures and better implants for surgical procedures in the treatment of CAvFs, remains to be established. Therefore, our study aimed to (1) perform a descriptive evaluation of CAvFs, including cases managed nonsurgically, and (2) assess surgical procedures, including the incidence of complications and reoperation for surgically treated CAvFs. In this multicenter retrospective study, we collected data of patients with CAvFs treated at 9 hospitals from 2012 to 2022. We performed a descriptive study of CAvFs and compared postoperative complications and reoperation rates for multiple surgical techniques and implants. The size of the bone fragments was quantified. The data of 70 patients with CAvFs were analyzed; 20 patients were treated nonsurgically, and 50 were treated surgically. The mean age of patients was 68.5 years; 67% of the patients were female. Nineteen percent of the patients had diabetes, and 19% had osteoporosis. The incidence of postoperative complications was 30%, with infection in 14%, necrosis in 26%, and loss of reduction in 18%. The reoperation rate was 22%. Surgical techniques with use of cannulated cancellous screws were performed in 80% of the surgical cases. Cannulated cancellous screw (CCS) fixation alone resulted in a reoperation rate of 35%, whereas additional augmentation, including washers with CCS fixation, resulted in a reoperation rate of 10%. CCS fixation was successfully performed, although suture anchors were used in some cases with smaller fragments. CAvFs occurred more frequently in older women and had a high rate of postoperative complications. A combination of CCS with augmentation was more effective at reducing postoperative complications than CCS fixation alone, even when the bone fragment size was small. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

A 75-year-old with left ankle pain.

A 75-year-old female with a history of smoking presented with left foot pain after a fall. She was cleaning her pool when she lost her footing while walking down a step. On extremity examination of her left ankle, there was plantar flexion weakness, a palpable dell at the insertion of the Achilles tendon, and a bony mass proximal to the gap (Figure 1). Left ankle radiographs were remarkable for an acute fracture of the posterior proximal aspect of the left calcaneus (Figure 2). Before surgery, the skin had become ecchymotic and edematous. The patient underwent open reduction with internal fixation with podiatric surgery. As there was enough bone remaining, 2 cannulated screws were placed to fix the fracture along with the attached Achilles tendon. The patient was discharged with a recommendation of non-weight-bearing status for the left lower extremity, a cast, and orthopedic follow-up in 2 weeks. Calcaneal fractures account for 1%–2% of all fractures. Calcaneal avulsion fractures account for less than 3% of calcaneal fractures.1 The calcaneus is the largest tarsal bone; it supports axial load from the body. This report demonstrates a type 2 calcaneal avulsion fracture; a “beak fracture” where the tendon pulls on the tuberosity causing a horizontal fracture.2 It also demonstrates a rare tongue-type fracture where the tuberosity splits into a superior and an inferior fragment.3 Patients often present with pain, swelling, and ecchymosis near the posterior aspect of the calcaneus. Patients can have skin tenting that can lead to skin necrosis if not treated.3 This woman had ecchymosis before surgery but did not have skin necrosis. It is important to assess these patients for neurovascular compromise and signs of other injuries. A plain radiograph is usually sufficient for diagnosis. Treatment depends on the severity. Fractures with skin tenting, neurovascular injury, or significant displacement will likely require open reduction and internal fixation in the operating room.4 This research was supported (in whole or in part) by HCA Healthcare and/or an HCA Healthcare affiliated entity. The views expressed in this publication represent those of the author(s) and do not necessarily represent the official views of HCA Healthcare or any of its affiliated entities.

The Use of Headless Screws in the Setting of an Acute Posterior Calcaneal Avulsion Fracture in the Pediatric Population: A Case Report

Background: Sever’s is the most common cause of heel pain in the pediatric population and increases the risk of calcaneal apophyseal avulsion fractures. This is an uncommon fracture that faces problems with tenuous soft tissue coverage and high shear forces at the fracture site. Multiple fixation techniques have been employed in addressing this injury, with no one method standing out as superior. Case Presentation: We present a case of a 13-year-old male with a calcaneal apophyseal avulsion fracture in which cannulated headless compression screws were used for fixation. This was found to provide adequate compression across the fracture with minimal hardware prominence. This also allowed for the injection of radiopaque solution through the cannulated screw to rule out subtalar intraarticular penetration. We believe this represents a novel method of addressing these injuries. Conclusion: Cannulated headless compression screws are a suitable fixation technique for pediatric apophyseal avulsion fractures that provide the added benefit of assessment of intra-articular penetration of the subtalar joint by the injection of radiopaque solution through the cannulated screw.

A case of negative pressure wound therapy for postoperative infection of calcaneal avulsion fracture

A case of negative pressure wound therapy for postoperative infection of calcaneal avulsion fracture

A case of partial tear of the achilles tendon with calcaneal avulsion fractures

A case of partial tear of the achilles tendon with calcaneal avulsion fractures

Surgical treatment of calcaneal avulsion fracture with SpeedBridgeTM

Surgical treatment of calcaneal avulsion fracture with SpeedBridge^TM

Calcaneal Avulsion Fractures: A Multicenter Analysis of Soft-Tissue Compromise and Early Fixation Failure.

To characterize the presentation and outcomes of calcaneal avulsion fractures. Case series. Two ACS Level I trauma centers. Forty-seven calcaneal avulsion fractures isolated from a cohort of 1365 calcaneus fractures treated over a 17-year period. We collected instances of soft-tissue compromise at presentation, evidence of implant failure or fracture displacement after fixation, and reoperation. Forty-one patients were treated operatively, and 6 were treated without surgery. Twenty-one patients (44.7%) had either soft-tissue compromise or an open fracture necessitating urgent treatment at the time of presentation. Of those patients treated operatively with 3-month follow-up (n = 39), 28.2% of patients (11/39) had evidence of implant failure or fracture displacement. Age was the only predictor of catastrophic fixation failure (P = 0.01). The use of washer(s), suture anchor(s), or addition of soft-tissue procedures (eg, Strayer) did not have a significant effect on failure rate. Neither the number of screws used nor size of screw impacted the failure rate. Fourteen patients (35.9%) underwent a secondary operation. Avulsion fractures of the calcaneus commonly present with soft-tissue compromise and have a significant rate of treatment failure and reoperation. This injury should be identified early and approached thoughtfully, acknowledging that risks are high. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Bone Anchor Suture Tape Fixation Technique for the Treatment of Calcaneal Avulsion Fractures

Category:Hindfoot, TraumaIntroduction/Purpose:Surgical treatment of avulsion fractures of the calcaneus has a reported fixation failure rate as high as 23%, and there is much controversy surrounding the best method of treatment for these fractures. We present a technique for fixation of calcaneal avulsion fractures utilizing a bone anchor suture tape fixation technique that can be utilized with or without additional standard internal fixation.Methods:Five patients (2 male, 3 female), with an average age of 73 years old, presenting with a closed extraarticular avulsion fracture of the calcaneus, are included in this case series. Patients underwent bone anchor and suture tape fixation of fracture by a single foot and ankle-fellowship trained orthopaedic surgeon. Patients were additionally assessed pre-operatively, using the contralateral uninjured limb, for gastrocnemius equinus; and if present, patients underwent a gastrocnemius recession. If appropriate, a single compression lag screw and washer inserted perpendicular to fracture line was utilized for additional fixation. Outcomes observed were time to radiographic consolidation, failure of fixation, reoperation rate, presence of post-operative infection, and return to previous function.Results:Of the included patient cohort, all fractures went on to union, and there were no failures of fixation. There was one removal of a compression screw and washer due to hardware pain, and one superficial infection, which resolved with local wound care. All patients went on to weight-bearing as tolerated within 8 weeks post-operatively. Radiographic consolidation was observed at approximately 12 weeks. 4 out of 5 patients returned to previous function, with 1 patient expiring due to unrelated causes prior to determination of final function.Conclusion:Use of a bone anchor suture tape fixation technique appears to hold promise and warrants further investigation for its potential utilization as a reliable technique for fixation for avulsion fractures of the calcaneus. Our technique increases the distribution of surface area forces over the cortical bone while incorporating multiple points of fixation, including through the Achilles tendon insertion, neutralizing the distraction forces of the tendon directly.

Treatment of calcaneal avulsion fracture of the Achilles tendon with suture anchor : Report of two cases

Treatment of calcaneal avulsion fracture of the Achilles tendon with suture anchor : Report of two cases

Calcaneal avulsion fracture of Achilles tendon enthesis treated with anchor suture fixation

Calcaneal avulsion fracture of Achilles tendon enthesis treated with anchor suture fixation

Achilles tenodesis for calcaneal insufficiency avulsion fractures associated with diabetes mellitus

BackgroundCalcaneal insufficiency avulsion (CIA) fractures often present with neuropathic etiology, such as Charcot neuroarthropathy (CN). Under the same surgical procedures, the outcomes of CIA fractures are less desirable, compared to the outcomes of the traumatic calcaneal avulsion fractures. Here, the study suggests Achilles tenodesis technique using suture anchor after resection of the CIA fracture fragments could provide satisfactory clinical results in the cases of surgically indicated CIA fractures.Materials and methodsThis retrospective study included seven patients of calcaneal avulsion fracture who had underlying diabetes mellitus (DM) and no specific traumatic event. The patients were treated with Achilles tenodesis techniques for their CIA fractures. Achilles tenodesis was performed using suture anchor with removal of the fracture fragments. The patients were evaluated with the Foot and Ankle Outcome Score (FAOS), visual analogue scale (VAS), single-heel rise test, and X-ray images on their final follow-ups.ResultsInitially, three of the CIA fracture cases treated with traditional open reduction and internal fixation reported pullout failure. Consequently, all patients received Achilles tenodesis using suture anchor after bone fragment resection and had good clinical outcomes. Only one subject with low compliance reported poor outcome.The FAOS of each patient were obtained at a mean of 16.3 months after surgery. The results are as follows: pain 80.6 (SD = 6.2), symptom 83.8 (SD = 4.9), activities of daily living 80.5 (SD = 8.0), sport and recreation function 75.6 (SD = 11.93), and foot- and ankle-related quality of life 77.9 (SD = 6.7). On their final follow-ups, the average VAS was 2.6 (range, 1 to 4).ConclusionAchilles tenodesis using suture anchor after bone fragment resection achieved competent clinical results in the patients with CIA fractures. The study proposes that this surgical procedure could be an appropriate treatment option for patients with CIA fractures.Trial registrationThe study was approved by the institutional review board (IRB) of our medical center (IRB File No. 2016-07-043), retrospectively registered.

A Novel Technique for Calcaneal Avulsion Fracture: A Case Report

Avulsion fractures of the calcaneal tuberosity constitute only a small percentage of calcaneal fractures. Avulsion fractures often occur in elderly women with osteoporosis. Various surgical methods are used in the treatment of this type of fracture. These include tension band wiring, suture anchor fixation, lag screw fixation, and TightRope® technique. In order to manage these fractures effectively, it is important to avoid skin necrosis and to ensure strong fixation that can resist the pull of triceps surae. We performed a novel technique using Achilles SpeedBridge™ and a cannulated lag screw. This technique allows for strong and easy fixation. A 57-year-old man presented to our department with a left ankle injury caused by slipping on a rocky area next to the sea. We diagnosed a type I calcaneal avulsion fracture, and planned surgical fixation. Surgery was performed 3 days after the injury. Postoperatively, the patient used a brace to maintain the ankle in the natural position for three weeks. Full weight bearing was started with Achilles boots after the brace was removed. His ankle range of motion was 30° plantar flexion and 60° dorsiflexion. He could perform all movements without any issues and without requiring support. His preoperative American Orhopaedic Foot and Ankle Society score was 52/100, and after 3 months this had increased to 100/100. We believe that this technique is highly effective for the treatment of type I calcaneal avulsion fractures.

Surgical Treatment of Calcaneal Avulsion Fracture in Elderly Patients Using Cannulated Cancellous Screws and Titanium Wire

Avulsion fractures of the calcaneus are relatively uncommon and are seen most frequently in elderly or osteoporotic patients. A surgical method that avoids displacement of the avulsed fragment after fixation has not been developed. We report the cases of 3 patients (a 73-year-old male, an 85-year-old male, and an 81-year-old female) treated by open reduction and internal fixation using titanium wire and cannulated cancellous screws. The posterior approach was used by way of a vertical midline incision. The fracture was fixed with 2 screws, and then a titanium wire was passed through the holes of the cannulated screws. A small incision on the lateral side of planter was added for the exit and return of the wire. The wire knot was bent inside the proximal Achilles tendon bursa in 2 patients and was directed to the plantar side in 1 to avoid irritation. Bony union was achieved without repeat displacement of the fragment in all 3 patients. Normal ankle function was restored, and the patients recovered the activities of daily living almost to the original level. Although an additional plantar incision is required, this surgical technique provides strong internal fixation.

Bilateral Calcaneal Avulsion Fracture Complicated with a Delayed Achilles Tendon Rupture in a Patient with Diabetes: A Case Report.

A sixty-five-year-old man with diabetes mellitus had bilateral calcaneal avulsion fracture without a history of trauma. Both fractures were treated surgically with modified tension-band wiring, cerclage wiring, and screws. Six months after the surgery on the left side, the patient had a left Achilles tendon rupture proximal to its insertion into the calcaneus. Calcaneal avulsion fractures are rare but often have complications. Even if these fractures are managed by well-established treatment methods, an unanticipated complication, namely a delayed Achilles tendon rupture, can occur in patients with diabetes.

Calcaneal Avulsion Fractures

The purpose of this study was to evaluate prognostic predictors of complications and need for secondary surgery in a series of calcaneal avulsion fractures. Thirty-three patients who sustained extra-articular calcaneal avulsion fractures from 2002 to 2011 were retrospectively identified. Main outcome measurement was need for secondary surgical procedures. Secondary complications such as soft tissue complications and loss of fixation were noted. Prognostic factors for outcome measures were identified. There was a need for secondary operations in 12 cases. Of those, 10 (83%) had wound complications and 5 (41.7%) had failure of fixation. Two subjects required below knee amputation. Of the entire cohort of 33 patients, 13 (39.4%) had soft tissue complications. Of the 22 that underwent surgery, 6 (27%) had failure of fixation. Increased age was significantly associated with wound complications (P = .029). Hypothyroidism (P = .003), peripheral vascular disease (P = .022), and presence of more than one comorbidity (P = .005) were significantly associated with need for secondary surgical intervention. Skin compromise at presentation was significantly associated with soft tissue complication (P = .036) and failure of fixation (P = .046). Calcaneal avulsion fractures have a high incidence of soft tissue problems, failure of fixation, and need for additional surgeries. Comorbid conditions and increased age portend a poor prognosis with a significant association with wound complications and need for additional surgeries. Prognostic, Level II: Retrospective Analysis.

Conservative treatment of a calcaneal avulsion fracture partly consisting of a large bone spur

Conservative treatment of a calcaneal avulsion fracture partly consisting of a large bone spur

Calcaneal Tuberosity Avulsion Fracture: An Unusual Variant

Calcaneal tuberosity fractures involve the posterosuperior aspect of the calcaneus and may involve the insertion of the Achilles tendon. In this report, we describe an unusual presentation of a calcaneal avulsion fracture involving 2 displaced fragments in a male patient who did not seek treatment for 1 month after the original injury. The larger fragment contained the insertion of the Achilles tendon, and tendon lengthening was required in addition to fixation of the fracture fragments with cannulated lag screws and washers. After reduction and healing, the patient recovered fully without clinical weakness of the triceps surae.

Avulsion Fracture of the Calcaneal Tuberosity: Classification and Its Characteristics

BackgroundNot much is known regarding avulsion fractures of the calcaneal tuberosity. We propose a modified classification scheme that presents the four types of calcaneal avulsion fracture as described by surgical and magnetic resonance imaging (MRI) findings, and evaluation of their specific features.MethodsOut of 764 cases of calcaneal fractures, we examined 20 cases (2.6%) that involved the tuberosity of the calcaneus. Each case was classified depending on the avulsed fracture patterns as follows; type I is a 'simple extra-articular avulsion' fracture, type II is the 'beak' fracture, type III is an infrabursal avulsion fracture from the middle third of the posterior tuberosity, and finally in type IV there is the 'beak', but a small triangular fragment is separated from the upper border of the tuberosity. We examined the features of each avulsed type according to several criteria including patient age, gender, anatomical variances of the Achilles tendon, the fibers involved and the mechanism of injury.ResultsThe type I fracture (8/20 cases) was the most common and likely to occur in elderly women. However, in other types, they were more common in relatively younger male patients. Type I were usually caused due to an accidental trip causing a fall by the patient. However, the dominant cause of type II (5/20 cases) fractures a direct blow or hit directly to the bone. Type III (4/20 cases) and IV (3/20 cases) fractures were likely to occur due to falling. All fibers within the Achilles tendon are involved in both type I and II fractures. However, only the superficial fibers are involved in type III fractures, whereas the deep fibers are involved in type IV fractures.ConclusionsThe avulsion patterns of the calcaneal tuberosity fractures are the result of several factors including the bony density level, the mechanism of injury and the fibers of the Achilles tendon that transmit the force. Accurate diagnosis of type III and IV is dependant on MRI technology to confirm the specific location of the injury and provide proper patient treatment therapeutics.

Modified Tension Band Wiring Fixation for Avulsion Fractures of the Calcaneus in Osteoporotic Bone: A Review of Three Patients

Calcaneal avulsion fractures are not uncommon, and they are probably more likely in patients with osteoporosis. Closed manipulation for this type of fracture often fails to achieve acceptable reduction, and open reduction and internal fixation are usually required. However, open reduction and internal fixation with either a lag screw or Steinmann pins do not provide satisfactory fixation in patients with diabetes and elderly patients because of the presence of porotic bone. Levi described a tension band fixation system used to treat a calcaneal avulsion fracture using a simple technique performed with a transverse Kirschner wire through the os calcaneus, securing a figure-of-8 metal tension band wiring to the fragment. We report the successful treatment of 3 patients with calcaneal avulsion fractures using a modified tension band wiring technique, resulting in satisfactory recovery. Re-displacement of the fragment during the initial follow-up period was not reported, and bony union was achieved in all patients. We believe this technique is a useful surgical option for the treatment of calcaneal avulsion fractures.

Double Row Anchor Fixation: A Novel Technique for a Diabetic Calanceal Insufficiency Avulsion Fracture

Avulsion fractures of the calcaneal tuberosity represent only 1.3% to 2.7% of calcaneal fractures. These fractures are common pathologically in nature and attributed to decreased bone mineral density. Calcaneal insufficiency avulsion (CIA) fracture in patients with diabetes mellitus is most likely due to Charcot neuroarthropathy (CN) as described by the Brodsky classification (Brodsky 3B). Traditional open reduction and internal fixation is difficult in all calcaneal avulsion fractures because of poor bone quality. The authors report the first known description of the use of fracture fragment excision and double row anchor fixation.A 39-year-old woman with type I diabetes mellitus and a history of CN presented with an avulsion fracture of the calcaneal tuberosity. Excision of the fracture fragment and a gastrocnemius recession and reattachment of the Achilles tendon with double row anchor fixation to the calcaneus were performed. At 1 year, the patient’s American Orthopaedic Foot & Ankle Society rearfoot score improved from 27/100 to 88/100. CIA fractures are an infrequently described injury. Because diabetes mellitus is frequently associated with this disease, it most likely represents a CN event. Traditionally, CIA fractures have been operatively treated with open reduction internal fixation. Previous authors have described difficulty with fixation because of poor quality. In the current report, the authors describe a novel operative approach to CIA fractures through the use of double row anchor fixation and excision of the fracture fragments. The authors feel that this previously undescribed treatment is superior to traditional methods and may serve as a new treatment option for all patients who have sustained this unusual pathology regardless of the underlying cause. The current authors provide a novel operative technique that provides inherent advantages to the traditional repair of CIA fractures. We believe CIA fractures represent a CN-type event and care should be taken when evaluating and treating these patients to prevent further sequelae.