Modified tension band wiring fixation for avulsion fractures of the calcaneus in osteoporotic bone: a review of three patients

Calcaneal tuberosity avulsion fractures - A review

Calcaneal tuberosity avulsion fracture, an extra-articular injury, is a rare fracture caused internally by Achilles tendon driven following intense contraction of gastrocnemius-soleus complex, and externally by low-energy (possibly high-energy). Moreover, the risk of injuries of the skin and Achilles tendon around calcaneal tuberosity is closely related to Lee classification and Carnero-Martín de Soto Classification of calcaneal tuberosity avulsion fracture. Although the diagnosis confirmed by X-ray, digital imaging and computed tomography (CT), magnetic resonance imaging (MRI) should also be used to evaluate soft tissue. In recent years, the understanding of this fracture has witnessed the development of different internal fixation devices and surgical procedures. These advances have been further elaborated scientifically in terms of their ability to provide stable fracture reduction ad resistance to Achilles tendon forces. In order to obtain a comprehensive knowledge of the disease, this article reviewed the new understanding of the anatomy, typing, risk factors, and treatment modalities of calcaneal tuberosity avulsion fracture in recent years.

An Alternative Technique for Fixation of Tongue-Type Calcaneal Fractures: The "Hurricane Strap"

Traditionally, tongue-type calcaneal fractures have been treated using screw fixation or tension band wiring. In this work, we aim to present a technique guide for an alternative approach to fixation of these fractures given the high potential for failure with traditional methods. Additionally, we present the results of 4 patients treated with this technique. A modified lateral extensile incision is made for application of a midfoot fusion plate that is pre-bent and fit to the calcaneus with 2 holes covering the superior surface of the calcaneus for bicortical interfragmentary purchase. Four screws are then placed orthogonally into the calcaneus through the plate. Typically, this allows for 2 screws to be placed in the superior fragment and 2 screws to be placed in the inferior fragment. All 4 patients went on to timely osseous union and were weightbearing in regular shoe gear at their last follow-up appointment. Average follow-up time was 16.5 (range 15 to 21) months. We believe that the "hurricane strap" provides a more mechanically sound construct than other methods. This construct may be especially useful in patients with osteoporotic bone where screws alone may not maintain adequate reduction or in neuropathic patients where noncompliance with weightbearing status may jeopardize maintenance of reduction.

The Treatment of Avulsion Fracture of the Calcaneal Tuberosity: A New Technique of 180-Degree Annular Internal Fixation

Due to the traction of the Achilles tendon and osteoporosis, a large number of reports have shown that a series of complications such as skin flap necrosis and failure of internal fixation after surgery often cause nonunion or malunion of calcaneal tuberosity fractures. At the same time, there is no uniform standard for the operative procedure in the treatment of the avulsion fractures of the calcaneal tuberosity. We presented a new technique for the treatment of avulsion fractures of the calcaneal tuberosity, which is fixed with a 180-degree microplate. We aim to provide a simple, safe, and strong internal fixation technique for avulsion fractures of the calcaneal tuberosity as one of the treatment options.

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

OBJECTIVE

To characterize the presentation and outcomes of calcaneal avulsion fractures.

DESIGN

Case series.

SETTING

Two ACS Level I trauma centers.

PATIENTS/PARTICIPANTS

Forty-seven calcaneal avulsion fractures isolated from a cohort of 1365 calcaneus fractures treated over a 17-year period.

MAIN OUTCOME MEASUREMENTS

We collected instances of soft-tissue compromise at presentation, evidence of implant failure or fracture displacement after fixation, and reoperation.

RESULTS

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.

DISCUSSION

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.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Surgical treatment of avulsion fracture around joints of extremities using hook plate fixation

Purpose

This study proposed to access the clinical outcome of avulsion fractures around joints of extremities using the hook plate.

Methods

A total of 60 patients with avulsion fractures of joints admitted in our hospital between January 2011 and June 2016 were performed the surgery of hook plate fixation. Functional recovery was evaluated using the Lysholm knee score, Kaikkonen ankle injury score, Mayo elbow and wrist function score, and Neer shoulder function score.

Results

All the patients were healed within 3 months after surgery with stage I healing incision without vascular or nerve injuries. The average follow-up period was 18.1 months. At the last follow-up, no instability of joints, looseness of internal fixation or traumatic arthritis was observed. Mild joint fibrosis occurred in 5 cases. A total of 57 patients were well recovered with the excellent and good rate of 95%. Three patients with humeral avulsion fracture of the greater tuberosity had shoulder joint adhesion and peri humeral inflammation at the last follow-up due to the poor cooperation for early rehabilitation exercise. In the last follow-ups, the functional score of the affected limb was markedly greater than that in the 3-month follow-ups (p < 0.05).

Conclusion

Hook plate fixation has the therapeutic effect on treating avulsion fractures around joints of extremities with the advantages of reliable fixation, early rehabilitation after operation, high recovery rates of joint function, wide indications, and convenient uses.

Avulsion Fractures of Posterior Calcaneal Tuberosity: Identification of Prognostic Factors and Classification

Avulsion fractures of the posterior calcaneal tuberosity are rare injuries, and little is known about the underlying factors, outcomes, and prognosis. Furthermore, classifications described previously focus on fracture morphology, with uncertain clinical utility. We present the results of a retrospective study of 21 patients treated for this pathology from January 2002 to December 2015. Features analyzed were age; sex; mechanism of injury; medical comorbidities; type of fracture, as proposed by Beavis; fracture displacement; fragment size; type of treatment; complications; need for secondary surgery; and the American Orthopaedic Foot and Ankle Society score after treatment and follow-up care. Mean age was 56.95years. A total of 61.9% were females, and 71.4% were secondary to low-energy trauma. In addition, 19% were diabetic. Mean follow-up was 57.24 months. Surgery was performed in 81%. Complications rate was 61.9%, and secondary surgery was needed in 38.1%. Mean fracture displacement was significantly higher when complications occurred (25.91mm versus 7.61 mm) (p = .03) and when soft tissues complications appeared (30.65mm versus 14.68 mm) (p = .02). Female gender was associated with the secondary loss of reduction (p = .04). The Beavis classification was not related significantly with any outcome variable. When fracture displacement was ≥2cm, complication rate increased from 30% to 90.9% (p = .008) and soft tissue compromise increased from 0% to 45.45% (p = .035). A new classification system with prognostic value is described, based on fracture displacement. We present 1 of the largest series published to date; fracture displacement is a major variable that influences the outcomes of these injuries, and a new classification attending to a prognostic factor is developed.

Combined Lag Screw and Cerclage Wire Fixation for Calcaneal Tuberosity Avulsion Fractures

Avulsion fractures of the calcaneal tuberosity represent a rare injury pattern that is caused by a powerful tension force from the Achilles tendon and is usually seen following minor trauma, especially in elderly patients. The objective of this study is to describe a surgical technique using cerclage wiring through cannulated screws in the treatment of extra- and intra-articular avulsion fractures of the calcaneal tuberosity and to present our results in a small patient's cohort. Through a 5.0 cm longitudinal skin incision over the posterolateral aspect of the calcaneus, after adequate debridement of the fracture fragments and while keeping the ankle in plantarflexion, the calcaneal tuberosity is anatomically reduced with the help of a periarticular reduction clamp and an accessory plantar longitudinal approach. Provisionally fixation is performed with K-wires. Definitive fixation is achieved with two parallel partially threaded 7.0 cannulated screws, which are positioned from the superior and posterior aspect of the tuberosity to the inferior and anterior aspect of the plantar surface of the calcaneus, and 1.5 mm cerclage wires that are pulled epiperiosteally to the plantar aspect of the calcaneus to avoid damage to local soft tissues. Alternatively, for smaller fracture fragments, two 3.5 mm partially threaded cannulated screws and 1.25 mm cerclage wires can be used. We also report the results of the procedure in a small cohort of four patients. All fractures healed in an anatomic position. There was no failure of fixation, loss of reduction, or need for secondary surgery, including hardware removal. At final follow-up, all patients had regained full plantar flexion range of motion and strength, with no gait or weight-bearing restrictions. In conclusion, the combination of cerclage wire and large diameter cannulated screws represents a promising option in the treatment of avulsion fractures of the calcaneal tuberosity, demonstrating good functional and radiographic results in our cohort of patients.

Avulsion fracture of the posterosuperior tuberosity of the calcaneus managed with lag screw fixation

BACKGROUND

To review the efficacy of lag screw fixation in management of avulsion fracture of the posterosuperior tuberosity of the calcaneus.

METHODS

Since 2002, thirteen patients with displaced fracture of the posterior tuberosity of the calcaneus were treated with emergency reduction of the fracture and lag screw fixation. The medical records and radiographs of the patients were reviewed and the patients were assessed according to the Kerr calcaneal fracture scoring system during the latest follow up.

RESULTS

There was no skin necrosis, but one wound dehisced in a patient with unstable diabetes and hypothyroidism. All fractures healed, but two had separation of the fracture fragments after the plaster was removed, both of them were elderly osteoporotic patients. The overall average calcaneal score was 93 (range, 77-100). The average calcaneal score of the patients with closed reduction was 91 (range, 77-100). The average calcaneal score of the patients with open reduction was 94 (range, 79-100). Complications occurred in seven patients (54%).

CONCLUSIONS

Percutaneous or open reduction of the avulsion fracture of the posterosuperior tuberosity of the calcaneus together with lag screw fixation and equinus short leg cast immobilization can provide good results without skin necrosis. The surgeon should pay attention of the details of the operation and the rehabilitation program in order to minimize the complications.

Radiographic and functional outcomes after displaced intra-articular calcaneal fractures: a comparative cohort study among the traditional open technique (ORIF) and percutaneous surgical procedures (PS)

BACKGROUND

Open reduction with internal fixation (ORIF) and percutaneous surgery (PS) are the most common surgical procedures for the treatment of displaced intra-articular calcaneal fractures. The purpose of this retrospective study was to compare the clinical and radiological results of these techniques and to verify the prognostic value of the radiographic measurement tools proposed in the literature.

METHODS

A consecutive series of 104 calcaneal fractures was included in this analysis. Essex-Lopresti and Sanders classifications were used to evaluate the injuries, and their prognostic correlation was tested. Böhler's angle was measured pre- and postoperatively and evaluated as radiological outcome. Clinical outcomes were evaluated using the American Orthopaedic Foot and Ankle Society hindfoot scale (AOFAS), Maryland Foot Scale (MFS), 17-Foot Function Index (FFI), Short Form-36 (PCS), and a 10-point visual analogue scale (VAS).

RESULTS

A total of 87 fractures (5 bilateral), 54 in males and 28 in females, were evaluated with a mean follow-up of 77.0 months. Overall mean age was 51.6 years old. The most frequent cause of trauma was a fall from a height. According to Essex-Lopresti, there were 58 joint depression fractures, 26 tongue, and 3 comminute. According to Sanders: 37 type II, 31 type III, and 19 type IV. Patients were divided into three groups according to surgical treatment: 19 in the ORIF group, 35 in the PS Screw group, and 33 in PS K-wire group. The ORIF group obtained significantly better results (82 AOFAS, 86 MFS, 19.6 FFI, 46.2 PCS, 8 VAS) with respect to the PS K-wire group (74 AOFAS, 76 MSF, 26.4 FFI, 40.8 PCS, 6 VAS). The PS Screw group obtained intermediate results (79 AOFAS, 82 MFS, 22.4 FFI, 41.6 PCS, 7 VAS). The restoration of the Böhler's angle was achieved most frequently (p = 0.02) in the ORIF group, without better clinical results.

CONCLUSION

The results were best in the ORIF group, despite its risk of complications, inferior in the PS Screw group, however without statistical significance (p > 0.05), and worse in the PS K-wire group. Finally, our data confirmed the prognostic correlation between the two radiographic classifications used and the clinical outcomes.

Calcaneal Tuberosity Fixation Using a Locking Compression Hook Plate

Calcaneal tuberosity fractures account for 1% to 3% of all calcaneal fractures. Surgical fixation is particularly challenging owing to osteoporosis and numerous comorbidities and risk factors in this patient population. Numerous techniques have been proposed; however, we describe the use of a locking compression hook plate in the treatment of type 2 fracture patterns. This has the advantage of providing stable fixation in osteoporotic bone, avoiding the disadvantages of soft tissue and metalwork irritation that have been described with other techniques.

An avulsion fracture of the calcaneal tuberosity: delay of treatment causes the 'Achilles heel' of optimal recovery

A 72-year-old woman was diagnosed with an avulsion fracture of the tuberosity of the calcaneus. The fracture was planned for elective fixation 12 days after the accident. The planned open reduction and internal fixation was not possible due to a decubital wound on the Achilles heel as a result of pressure on the skin of the fractured tuberosity. Closed reduction and internal fixation was performed, leading to an acceptable outcome. Avulsion fractures of the tuberosity of the calcaneus are rare injuries, and delay in treatment should be avoided as it may lead to preventable complications.

Avulsion Fracture of the Calcaneus Treated With a Soft Anchor Bridge and Lag Screw Technique: A Report of Two Cases

The displaced extra-articular avulsion fracture of the calcaneus has been classified as a Böhler type 1c calcaneal fracture, and most cases will require surgical repair. In the present report, we describe 2 patients in whom we performed the soft anchor bridge technique using single loaded suture anchors with lag screws for the repair of Böhler type 1c avulsion fractures of the calcaneus. In one of these patients, clinically relevant osteoporosis complicated the injury. In both cases, bone union was achieved, and by 1.5 months after surgery satisfactory recovery was observed. To our knowledge, the soft anchor bridge technique was first used for the treatment of rotator cuff tears, and the greatest merit of this technique is the ability to generate vertical compression force to the pulled out rotator cuff through the use of knotting sutures. In recent years, the soft anchor bridge technique using 4 suture anchors has also been used for fractures of the greater tuberosity of the humerus, an injury that poses operative difficulties similar to those encountered with an avulsion fracture of the calcaneus owing to the traction force of the rotator cuff and relative weakness of adjacent bone. The outcomes of our patients suggest that the soft anchor bridge technique combined with adjunct lag screws is useful in the fixation of avulsion fractures of the calcaneus. In addition, the result in the elderly patient indicates the possibility of using this technique for patients with osteoporosis.

A new treatment for avulsion fracture of the calcaneus using an Ilizarov external fixator

INTRODUCTION

In the treatment of avulsion fractures of the posterior calcaneal tuberosity, open reduction and internal fixation are prone to several complications. We describe a new treatment using an Ilizarov external fixator, which can minimise the complications and achieve sufficient stability of the displaced fragment.

CASE PRESENTATION

A 55-year-old woman sustained an avulsion fracture of the calcaneus. Examination revealed the development of bruising with extremely taut skin over the posterior prominence of the displaced bone. Radiographs demonstrated grossly proximal displacement of the tuberosity fragment. Surgery was exclusively percutaneous using an Ilizarov external fixator. The displaced fragment was adequately reduced and stabilised. Progressive weight bearing in the equinus position was initiated at the third week after surgery and the external fixator was removed at the seventh week. There was no skin necrosis or loss of reduction while the fixator was maintained. Postoperative follow-up for 2 years revealed full recovery.

DISCUSSION

Major postoperative complications after conventional open reduction and internal fixation include skin necrosis, skin irritation by metal implants and re-displacement of the reduced fragment. Our method of using an external fixator may decrease the incidence of these three complications. Skin incision and the risk of skin necrosis are inevitable during internal fixation. On the other hand, the use of an external fixator reduces or eliminates skin necrosis, as it is applied percutaneously for reduction and stabilisation of the fragment. External fixation is mostly recommended in cases of poor vascularity or bruising. In addition, skin irritation can be avoided upon removal of the external fixator. Re-displacement occurs occasionally as a serious complication in lag screw fixation, particularly in cases with poor purchase of the osteoporotic bone. Tension band wiring and application of an Ilizarov external fixator in avulsion fractures of the calcaneus can neutralise tension on the Achilles tendon during the healing process. Thus, both these methods are believed to provide sufficient mechanical stability to fix the fragment.

CONCLUSION

This new method, involving application of an Ilizarov external fixator, is recommended when the avulsion fragment is large enough to accommodate Ilizarov wires, especially in cases of circulatory problems or bruising.