Fractures of the tuberosity of the calcaneus

Calcaneal Tuberosity Fracture With Complete Achilles Tendon Rupture: A Unique Surgical Challenge

A calcaneal tuberosity avulsion fracture occurring simultaneously with a rupture of the Achilles tendon, although occurring through similar mechanisms, is a rare injury pattern to see in combination and presents a unique challenge to the surgeon. The patient we present was initially found to have a type II fracture of the calcaneal tuberosity. However, during surgical fixation of the fracture, a complete rupture of the Achilles tendon was noticed. The technique used in this case was the fixation of the fracture fragment with two 5 mm fully threaded screws. The tendon was then reattached to the calcaneus using two Mitek anchors (DePuy Mitek Inc., MA, USA) with a modified Bunnell technique. There are a number of techniques suggested in the literature, including, among others, K-wires (DePuy Mitek Inc., MA, USA) and screw fixation. Our patient recovered well and has now been discharged from further orthopaedic follow-up.

Thickness of simple calcaneal tuberosity avulsion fractures influences the optimal fixation method employed

Aims

This study aimed to establish the optimal fixation methods for calcaneal tuberosity avulsion fractures with different fragment thicknesses in a porcine model.

Methods

A total of 36 porcine calcanea were sawed to create simple avulsion fractures with three different fragment thicknesses (5, 10, and 15 mm). They were randomly fixed with either two suture anchors or one headless screw. Load-to-failure and cyclic loading tension tests were performed for the biomechanical analysis.

Results

This biomechanical study predicts that headless screw fixation is a better option if fragment thickness is over 15 mm in terms of the comparable peak failure load to suture anchor fixation (headless screw: 432.55 N (SD 62.25); suture anchor: 446.58 N (SD 84.97)), and less fracture fragment displacement after cyclic loading (headless screw: 3.94 N (SD 1.76); suture anchor: 8.68 N (SD 1.84)). Given that the fragment thickness is less than 10 mm, suture anchor fixation is a safer option.

Conclusion

Fracture fragment thickness helps in making the decision of either using headless screw or suture anchor fixation in treating calcaneal tuberosity avulsion fracture, based on the regression models of our study.

Patient-Reported Outcome Following Operative and Conservative Treatment of Calcaneal Fractures: A Retrospective Analysis of 79 Patients at Short- to Midterm Follow-Up

Background: Fractures of the calcaneus are severe injuries of the hindfoot, mostly resulting from high-energy axial loads, which still present enormous challenges to modern trauma surgery. Possible variables influencing the outcome are the type of fracture, age, and quality of fracture reduction. These might also be factors affecting the self-reported patient outcome, but large studies are still lacking. Therefore, the aim of this study was to analyze the patient-reported outcome of calcaneal fractures following operative and conservative treatment.

Methods: All patients suffering from calcaneal fractures between 2002 and 2015 were enrolled in this retrospective analysis. The calcaneal fractures were classified according to Sanders and the AO classification system. For further analysis, two groups were formed: group I involved complex intra-articular fractures defined by the involvement of the posterior calcaneal facet, while group II consisted of extra-articular and process calcaneal fractures. Data were collected via the patient registry, radiographs, and a standardized questionnaire (Foot and Ankle Outcome Score, FAOS). For outcome analysis, non-parametric Mann–Whitney U-test was performed, and Spearman's rank correlation coefficient was calculated.

Results: In total, the functional outcome of 79 patients with calcaneal fractures was analyzed. In group 1 (n = 43), the mean FAOS score was 65.5 ± 18.9. The surgically treated patients with a Sanders type II calcaneal fracture had a mean FAOS score of 72.9 ± 17.2, type III fractures had 65.6 ± 20.8, and type IV had 61.1 ± 19 (p = 0.15). The reoperation rate was 22%, most frequently caused by wound complications (10%). The mean follow-up time was 64.5 ± 44 months. The mean FAOS score of group 2 (n = 36) was 75.2 ± 18.4, and 83% of the patients (=30) were managed conservatively. Only one out of six operatively managed patients had a reoperation due to regular implant removal. The mean follow-up time was 31 ± 25.9 months.

Conclusion: Intra-articular calcaneal fractures are severe injuries of the hindfoot leading to a fair to poor functional outcome in the majority of the patients. Complications regarding wound healing are the most common causes for revisional surgery. Extra-articular calcaneal fractures are a heterogenous entity commonly managed non-operatively. Overall, they show a better functional outcome in comparison to intra-articular calcaneal fractures.

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.

Stress shielding analysis on easy step staple prosthesis for calcaneus fractures

Objective

The calcaneus is the most frequently injured tarsal bone, with calcaneal fractures meaning that 60% of the fractures affect the foot and about 1%-2% of all fractures.

Methods

Two 3D FE model of the foot were realized in order to compare the stress shielding occurring in a health foot and in a fractured one implanted with an easy step prosthesis by Stryker. This dispositive is indicated for calcaneus fractures.

Results

Results evidence the efficacy of this kind of prosthesis as the Eq. Von mises stresses are comparable in the two model. Higher concentration of stress are concentered on the Easy step.

Conclusion

In conclusion, the easy step staple prosthesis allows obtaining excellent results in terms of calcaneus fracture treatments. The correct implant size for a given patient can be determined by evaluating the patient's height, weight, functional demands and anatomy.

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 Calcaneal Tuberosity: Case Report and Literature Review

Avulsion fractures of the calcaneal tuberosity are predominantly seen in patients with poor bone quality, the commonly used lag screw fixation might not be strong enough even with bony fragments of sufficient size. We present a case of a closed displaced avulsion fracture of the calcaneal tuberosity due to blunt trauma to the calf in a 74-year-old female. Open reduction and internal fixation with two 3.5-mm cannulated cortical screws with washers was performed, and anatomic reduction was achieved. Without further trauma, secondary displacement of the fracture occurred on day 3. Revision was performed with a single 3.5-mm cortical screw and transosseous fixation with 2 suture anchors, followed by partial weightbearing for 6 weeks. At 12 weeks postoperative, the fracture had completely healed, and she was doing well at 16 months after the revision surgery. Transosseous suture anchor fixation of an osteoporotic avulsion fracture of the calcaneal tuberosity seems to provide better and stronger fixation than that using lag screws.

Primary repair of Achilles tendon avulsions: Presentation of a novel technique and its comparison with suture anchor repair

PURPOSE

We aimed to present our novel technique in the surgical treatment of Achilles tendon avulsions and compare the clinical results of such technique with the repair method using suture anchors.

METHODS

A retrospective study was made of patients with Achilles tendon sleeve avulsion and patients where distal portion of the tear prohibited primary repair, surgically treated between January 2009 and January 2013. Twenty-one patients who met the criteria were examined and called for final examination: 9 patients were treated with the novel technique (group 1) and 12 patients were treated with suture anchor repair (group 2). Data were gathered from patient registry and final evaluation. The patients of both groups were compared in respect of mean age, follow-up, gender and AOFAS and VAS scores at final evaluation.

RESULTS

There was no significant difference between two groups in terms of follow-up period ( p = 0.478) and mean age ( p = 0.274). Three of 9 patients in group 1 and 4 of 12 patients in group 2 were female. A significant clinical difference was determined between two groups according to the AOFAS and VAS scores ( p = 0.034 and p = 0.043, respectively).

CONCLUSIONS

Both techniques are beneficial in the treatment of avulsion injuries of Achilles tendon. Better clinical results can be obtained with the presented novel technique and such technique can be considered for the surgical fixation of Achilles tendon avulsions.

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.

Calcaneal fractures: radiological and CT evaluation and classification systems

Background and aim of the work: The calcaneus, the more lower bone of the body, has the task of supporting the axial load from the weight of the body. Calcaneal fractures represent about 1-2% of all fractures and 60% of the tarsal bones fractures. The articular involvement has been associated with a poor functional outcome. The aim of this work is to describe the radiologic evaluation, the classification systems, the morphological preoperative diagnostic imaging features of calcaneal fractures, highlighting the correlation with the choice of treatment and predictive capacity for the fracture surgical outcome. Methods: A PubMed search was performed for the terms Imaging calcaneus fracture, selecting articles in English language, published in the last two years, where preoperatively diagnostic imaging of fractures of the calcaneus are described. Case reports have not been included. Results: We have collected a number of data that provide important help in preoperative evaluation of calcaneal fractures, such as the new classification system created by Harnroongroj et al, the association of calcaneal fractures with fractures of other bone structures or soft tissue impairment, the use of calcaneotalar ratio in assessing the length of heel. Conclusions: These data suggest an approach geared to the specific choice of treatment and to improving patient outcomes. (www.actabiomedica.it)

Reattachment using the suture bridge augmentation for Achilles tendon avulsion fracture with osteoporotic bony fragment

Although avulsion fractures of the calcaneal tuberosity are rare injuries, these can be a challenging problem with frequent complications, such as loss of reduction and soft tissue problem. Anatomical reduction and internal fixation are indicated to avoid these pitfalls and to restore function of the triceps surae. However, the best fixation device and operative technique are still controversial. A case that achieved satisfactory clinical outcome through a reattachment technique using the suture bridge augmentation for Achilles tendon avulsion fracture with osteoporotic bony fragment is presented.

Dual Fixation of Calcaneal Tuberosity Avulsion with Concomitant Achilles Tendon Rupture: A Novel Hybrid Technique

Fracture of the calcaneal tuberosity with a concomitant Achilles tendon rupture presents a difficult challenge for the treating surgeon. The ultimate goal of treatment is to restore function of both the gastrocnemius-soleus complex and the Achilles tendon. This particular subset of fractures occurs often in diabetics and elderly patients with osteoporosis making fixation of the displaced fragment rather complex. If the Achilles tendon disruption is only discovered later once the fracture is healed, subsequent management is difficult with surgical treatment being more morbid. While this is a rare injury, the consequences of a missed chronic Achilles tendon disruption are severe with significant dysfunction. It is therefore important to have a high index of suspicion for concomitant injury and to be prepared for dual fixation. We present a novel hybrid surgical fixation technique, which may be used in this instance.

Calcaneus Fractures: A Possible Musculoskeletal Emergency

BACKGROUND

Calcaneal fractures are commonly seen and treated in the emergency department. There are subsets of calcaneal fractures that pose a high risk to the adjacent soft tissue of the heel and can result in full-thickness tissue necrosis.

OBJECTIVE

To identify which calcaneal fractures need to be managed within hours and triaged to the orthopedic team and which can be temporized in a neutral or plantarflexed ankle splint and seen in an outpatient setting.

DISCUSSION

Tongue-type calcaneal fractures and tuberosity fractures must be triaged appropriately within the first few hours of presentation to prevent skin compromise. This requires the emergency physician to understand the radiographic morphology of the fracture as well as the clinical signs of skin compromise. Communication with the orthopedic surgery service is essential and splinting in a specific manner is important to stabilize the soft tissue envelope.

CONCLUSION

Recognizing the calcaneal injury pattern and implementing the correct treatment strategy is paramount to having successful patient outcomes. A delay or error in treatment can turn a closed fracture into an open fracture.

Characterization and Surgical Management of Achilles Tendon Sleeve Avulsions

BACKGROUND

An Achilles sleeve avulsion occurs when the tendon ruptures distally from its calcaneal insertion as a continuous "sleeve." This relatively rare injury pattern may not be appreciated until the time of surgery and can be challenging to treat because, unlike a midsubstance rupture, insufficient tendon remains on the calcaneus to allow for end-to-end repair, and unlike a tuberosity avulsion fracture, any bony element avulsed with the tendon is inadequate for internal fixation. This study aimed to highlight the characteristics of Achilles sleeve avulsions and present the outcomes of operative repair using suture anchor fixation.

METHODS

A retrospective analysis was conducted on 11 consecutive Achilles tendon sleeve avulsions (10 males, 1 female; mean age 44 years) that underwent operative repair between 2008 and 2014. Patient demographics, injury presentation, and operative details were reviewed. Postoperative outcomes were collected at a mean follow-up of 38.4 (range, 12-83.5) months, including the American Orthopaedic Foot & Ankle Society (AOFAS) Ankle-Hindfoot score, visual analog scale (VAS) for pain, plantarflexion strength, patient satisfaction, and complications.

RESULTS

Eight patients (72.7%) had preexisting symptoms of insertional Achilles disease. Ten of 11 (90.9%) injuries were sustained during recreational athletic activity. An Achilles sleeve avulsion was recognized preoperatively in 7 of 11 (64%) cases, where lateral ankle radiographs demonstrated a small radiodensity several centimeters proximal to the calcaneal insertion. Intraoperatively, 90.9% of sleeve avulsions had a concomitant Haglund deformity and macroscopic evidence of insertional tendinopathy. All patients healed after suture anchor repair. The average AOFAS score was 92.8 and VAS score was 0.9. Ten patients (90.9%) were completely satisfied. One complication occurred, consisting of delayed wound healing.

CONCLUSIONS

Achilles tendon sleeve avulsions predominantly occurred in middle-aged men with preexisting insertional disease, while engaged in athletic activity. Suture anchor fixation, combined with addressing concomitant insertional pathology, was a reliable and safe technique for the operative management of Achilles tendon sleeve avulsions. The majority of patients returned to their preinjury levels of work and recreational activity.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Patterns of Hamstring Muscle Tears in the General Population: A Systematic Review

Background

Hamstring tears are well recognised in the sporting population. Little is known about these injuries in the general population.

Purpose

Evaluating the rates, patterns and risk factors of non-sporting hamstring tears, compared to sporting related hamstring tears.

Data Sources

MEDLINE, EMBASE, CINAHL, and the Cochrane Central Register of Controlled Trials (1989–2015).

Study Selection

Studies reporting patients with a grade 2 or 3 hamstring muscle tear, identified clinically, confirmed by MRI imaging or direct visualisation during surgical exploration.

Data Synthesis

144 sets of linked data were extracted for analysis. Most injuries were in males (81.3%), where mean age at injury was lower (30.2, 95% CI 29.1–31.3) than in females (35.4, 95% CI 32.4–38.4) p = 0.06. Key differences were found in the proportion of non-sporting injuries in patients under and over the age 40 (p = 0.001). The proportion of non-sporting injuries was significantly higher in females compared to males (25.9% female non-sporting injuries, versus 8.5% male; p = 0.02). Avulsions were more frequently reported in non-sporting activities (70.5%). The proportion of such injuries was notably higher in females, though this failed to meet significance (p = 0.124). Grouped by age category a bimodal distribution was noted, with the proportion of avulsions greater in younger (age <15) and older patients (age > 40) (p = 0.008). 86.8% of patients returned to pre-injury activity levels with a similar frequency across all study variables; age, activity (sporting vs non-sporting) and injury type (avulsion vs tear).

Conclusion

This review highlights a proportion of adults suffering grade 2 or 3 hamstring injuries from activities other than the classic sports trauma. The majority of these non-sporting injuries were avulsion injuries that clustered in older female and skeletally immature patients suggesting a potential link to bone mineral density.

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.

Corrective Osteotomies for Malunited Extra-Articular Calcaneal Fractures

The most effective way to treat calcaneal malunions is avoidance. With any articular fracture, progressive arthrosis and dysfunction are common. By restoring the anatomy initially through reduction, late reconstructive options become less complicated. Numerous studies have shown that restoration of the anatomic alignment either through percutaneous or open techniques is effective. In patients with no or minimal articular degeneration, extrarticular joint-sparing procedures can be performed. This represents a small select group who may benefit from simple osteotomy procedures with associated soft tissue reconstruction, if needed.

Current management options for displaced intra-articular calcaneal fractures: Non-operative, ORIF, minimally invasive reduction and fixation or primary ORIF and subtalar arthrodesis. A contemporary review

BACKGROUND

Management of Displaced Intra-articular Calcaneal Fractures (DIACFs) continues to be technically demanding. The literature has not been definitive in its guidance for surgeons dealing with these injuries. Recent publications have further added to the lack of clarity. This review is intended to summarise the present state of knowledge, and provide some genuine guidance for clinicians.

OBJECTIVES

To review previous research, focussing on articles published within the last fifteen years, and summarise the findings to aid surgeons in managing DIACFs with choosing best management for patients.

METHODS

We reviewed the best evidence and literature, focussing on articles published within the last fifteen years, and summarised findings into workable recommendations. Variables of (1) patient, (2) the associated soft tissue injury and (3) the fracture characteristics were used to aid surgeons in choosing the best of the available options for each patient that presents with a DIACF.

AUTHORS SUMMARY

Management of DIACFs can best be divided into four broad categories: (i) non-operative management, (ii) open reduction and internal fixation, (iii) minimally invasive reduction and fixation, and (iv) primary subtalar arthrodesis. The evolution of the literature would suggest orthopaedic surgeons managing calcaneus fractures should have an expert's knowledge, surgical expertise and the latest techniques to cover these four options, to tailor the treatment of DIACFs to the individual patient.

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.

Open tuber calcaneus fracture caused by a meat cleaver: A case report

Introduction

Avulsion fractures of the tuber calcanei classically occur after falling on the foot, due to the forced dorsiflexion and the sudden contraction of the Achilles tendon. Direct trauma to the back of the leg and a direct penetrating injury are also infrequent causes and may be observed predominantly in younger patients.

Presentation of case

We present a case of an open tuber calcaneus fracture resulting from a penetrating trauma in a 37-year-old patient. The fracture was reduced through the open wound and fixed using two cannulated screws. Bone union was radiologically and clinically observed at the end of the first year.

Discussion

During a physical altercation, the posterior of the patient's heel was struck directly with a meat cleaver. The position of the patient during the trauma can be considered to have increased the severity and depth of the injury. In addition, even though the injury radiologically resembled an avulsion fracture and was caused by direct trauma, the fact that it was open and that the mechanism of injury differed from the norm means that it should not be evaluated as a classic avulsion fracture in the full sense. Emergency open reduction and internal fixation were applied to an open calcaneal tuberosity fracture, and the patient was started on intravenous antibiotic therapy.

Conclusion

Surgical techniques are successful in the treatment of open tuber calcanei fractures and an open intervention is usually required. Using cannulated screws is a good treatment option.

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Avulsion fractures of tuber calcanei are very rarely observed.

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Direct blunt trauma to the back of the leg and direct penetrating injury (gunshot) are also infrequent causes.

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Computed tomography is beneficial in specifying the type and size of the fracture.

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Anatomic reduction and early mobilisation are the advantages of surgical treatment.

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Delaying surgery may lead to skin necrosis and severe soft tissue complications.

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.

A tuber calcanei avulsion fracture developed on the basis of idiopathic osteoporosis in a young male: a case report

Calcaneus fractures constitute 1.2 % of all fractures. Tuber calcanei avulsion fractures constitute 1.3-2.7 % of calcaneus fractures. Osteoporosis, osteomalacia, and diabetes mellitus have been reported to increase the risk of development of these fractures. It has been reported that tuber calcanei avulsion fractures in elderly females might develop due to osteoporosis. As far as we know, no tuber calcanei avulsion fracture developing on the basis of osteoporosis without presence of a trauma has been reported in young males in the literature. In the current case report, a 41-year-old male patient who was admitted with complaints of pain in the left heel and diagnosed with calcaneal avulsion fracture that developed on the basis of idiopathic osteoporosis and who was treated with conservative methods was presented.

Avulsion fractures in the foot: telltale radiographic signs to avoid mismanagement

Due to similar clinical presentations, avulsion fractures are frequently missed on initial exam and categorically treated as "sprain" not otherwise specified. However, delays in appropriate diagnosis and treatment can result in further injury and long-term disability. This article will review multiple foot avulsion fractures, their respective mechanisms of injury, the clinical and radiographic presentations, and the most appropriate courses of treatment.

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.

The treatment of calcaneal malunion

The surgical treatment of calcaneal malunion is technically very demanding and requires a careful assessment of the exact cause of the problem. A number of different surgeries are available depending on the precise cause of symptoms. The results are reasonable and justify surgery in an otherwise disabled group of patients. Calcaneal malunion surgery should not be performed by the occasional surgeon, as the price of error is usually amputation.

Surgical management for avulsion fracture of the calcaneal tuberosity

OBJECTIVE

To discuss the operative methods and curative effect of calcaneal tuberosity fracture.

METHODS

A retrospective study was done to analyze 15 patients with calcaneal tuberosity fracture who received surgical management between January 2008 and June 2011. There were nine males and six females, with the age ranging from 31 to 68 years (average, 51.4 years). All the patients had unilateral acute injury, with the left foot in 7 cases and the right foot in 8 cases. According to the Beavis classification, there were three cases in type I and 12 cases in type II. All the cases in type I and 10 cases in type II were treated with open reduction and screw fixation. The other two cases in type II with larger fragment involving a portion of the subtalar joint were treated with plate and screw fixation. The effect of the treatment was assessed according to the ankle and hindfoot score system of American Orthopaedic Foot and Ankle Society (AOFAS) after the operation.

RESULTS

Ten patients were followed up for 12 to 36 months (average, 20 months). The healing time in these patients ranged from 8 to 25 weeks (average, 12 weeks). The postoperative score ranged from 47 to 100 points (average, 91.1 points). Seven cases were rated as excellent, two as good, and one as poor. The rate of excellent and good was 90%. Necrosis of skin and soft tissue and exposure of the plate happened in one patient, who eventually healed after 3 weeks by debridement with plate preserved and peroneal artery perforator flap transplantation. Loss of reduction happened to another patient, who was treated with revision surgery by open reduction and screw fixation again.

CONCLUSION

To patients with obvious fracture displacement, whose soft tissues are irritated severely, emergency open reduction and internal fixation operation should be offered to prevent the necrosis of the flaps as far as possible. To patients with small fractures, it is advisable to choose open reduction and large diameter screw fixation, while plate and screw fixation may be better for the patients with large fragments, especially for those with the fracture line extending to the subtalar joint.

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.

An alternative method of fixation of calcaneal tuberosity fractures using the Tightrope(®) technique

Calcaneal tuberosity fractures account for 1% to 3% of all calcaneal fractures. These fractures are frequently seen in the osteoporotic or diabetic elderly population. The patient's comorbidities, coupled with the usually osteoporotic bone, make fixing this fracture pattern a challenge. Numerous surgical techniques have been advocated for this fracture, including the standard lag screw fixation, tension band wiring, suture anchors, and direct suture repair. Whichever method is used, the construct must resist the massive pull of the gastrocnemius-soleus complex. We have described a method of fixing the avulsed calcaneal tuberosity using the TightRope(®) ankle syndesmosis fixation device (Arthrex(®), Naples, FL), which offers the advantages of allowing a robust and reliable fixation of a small or comminuted fragment. It is particularly advantageous in osteoporotic bone because of concern regarding the use of standard lag screw fixation, and it also may eliminate complications associated with retained hardware.

Tongue-type calcaneus fractures: a threat to skin

Calcaneal fractures account for 60% of all tarsal bone fractures. Tongue-type calcaneus fractures are longitudinal fractures that exit the calcaneal tuberosity posteriorly and involve a portion of the articular surface. They are often superiorly displaced because of the insertion of the Achilles tendon and pull of the gastroc-soleus complex. Skin compromise complicates a large percentage of these injuries because of the thin layer of soft tissue and superficial nature of the fracture. Early recognition by the emergency physician and prompt operative repair prevent further injury and obviate the need for surgical soft tissue coverage or potential amputation.

Avulsion fracture of the calcaneal tuberosity: classification and its characteristics

Background

Not 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.

Methods

Out 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.

Results

The 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.

Conclusions

The 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.

Management of calcaneal tuberosity fractures

Fractures of the calcaneal tuberosity are relatively uncommon and are seen most frequently in elderly and diabetic patients. These injuries are typically avulsion fractures caused by concentric contraction of the gastrocnemius-soleus muscle complex. Displacement of these fractures can compromise the skin over the posterior aspect of the heel; therefore, early recognition and management are imperative. Surgical management of calcaneal tuberosity fractures requires reduction and stable fixation of the displaced fragment. When the patient has preexisting tightness of the gastrocnemius-soleus complex, successful management must also address this pathology to improve outcome.

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.

Demographics of extra-articular calcaneal fractures: including a review of the literature on treatment and outcome

INTRODUCTION

Extra-articular calcaneal fractures represent 25-40% of all calcaneal fractures and an even higher percentage of up to 60% is seen in children. A disproportionately small part of the literature on calcaneal fractures involves the extra-articular type. The aim of this study was to investigate the incidence of extra-articular calcaneal fractures in a Level 1 trauma centre, define the distribution of the various types of fractures and compare patient demographics between extra- and intra-articular calcaneal fractures. In addition the literature was reviewed for the most common types of extra-articular calcaneal fractures with regard to incidence, treatment and clinical outcome.

METHODS

The radiological records between 2003 and 2005 were reviewed for intra- and extra-articular calcaneal fractures. Patient gender-distribution and age were compared. A literature search was conducted for the treatment of extra-articular calcaneal fractures.

RESULTS

In this 3-year study period a total of 49 patients with 50 extra-articular calcaneal fractures and 91 patients with 101 intra-articular fractures were identified. The median age for the first group was 32.7 years, and for the second group 40.3 years; P = 0.04. Male predominance was significantly less pronounced for extra-articular (63%) compared with intra-articular fractures (79%; P = 0.04).

CONCLUSION

One-third of all calcaneal fractures are extra-articular. Significant differences exist between the intra- and extra-articular groups, in terms of lower age and male-female ratio. The literature study shows inconsistencies in treatment options, but most extra-articular fractures are well manageable conservatively.

Mechanical alterations of rabbit Achilles' tendon after immobilization correlate with bone mineral density but not with magnetic resonance or ultrasound imaging

OBJECTIVE

To assess the usefulness of magnetic resonance imaging (MRI), ultrasound (US) imaging, or bone mineral density (BMD) in predicting the mechanical properties of immobilized rabbit Achilles' tendons.

DESIGN

Experimental study.

SETTING

Basic university laboratory.

ANIMALS

Twenty-eight rabbits.

INTERVENTIONS

Twelve rabbits had 1 hindlimb casted for 4 weeks and 10 rabbits were casted for 8 weeks. Contralateral legs and 12 normal hindlimbs served as controls.

MAIN OUTCOME MEASURES

Achilles' tendon dimensions on MRI and US, T1- and T2-signal intensities on MRI, classification of abnormalities on MRI and US; BMD of the calcaneus with dual-energy x-ray absorptiometry. Biomechanic measures consisted of peak load, stiffness, and stress. Imaging variables were correlated with biomechanic alterations.

RESULTS

Immobilized Achilles' tendons were weaker and showed decreased mechanical stress compared with their contralateral legs and controls (all P<.05). MRI and US revealed larger Achilles' tendons after immobilization. However, neither increased MRI nor US signal abnormality was found. BMD was lower in immobilized calcanei and larger in contralateral legs than controls. Only BMD correlated with both the decreased peak load (R2=.42, P<.05) and stress (R2=.54, P<.05) of immobilized Achilles' tendon.

CONCLUSIONS

This study established weakened mechanical properties of immobilized Achilles' tendons. BMD of the calcaneus, but not MRI and US, was predictive of the mechanical alterations in immobilized Achilles' tendons. BMD may be a useful biomarker to monitor disease and recovery in Achilles' tendons.

Fixation of calcaneal avulsion fractures using screws with and without suture anchors: a biomechanical investigation

BACKGROUND

Lag screw fixation commonly is used to treat avulsion fractures of the posterior calcaneal tuberosity, but this method may not offer reliable fixation. This study compared the strength to failure of lag screws compared to lag screw fixation augmented with suture anchors in these fractures.

METHODS

The calcanei and Achilles tendons of 12 fresh lower extremity cadaver matched pairs were dissected and removed. An oblique osteotomy was created in the calcaneus, and two 4.0-mm lag screws were placed nearly perpendicular to the plane of the fracture in the dorsal aspect of the calcaneus with 30 degrees of divergence between them. In the contralateral specimen, the same procedure was done, but with two suture anchors placed 1.5 to 2 mm distal to the osteotomy. A zigzag suture technique through the Achilles tendon was used. The specimens were mounted and placed in a load frame for monotonic loading to failure. A paired Student t-test and a Pearson correlation were used to analyze the data (p <or= 0.05).

RESULTS

The specimens treated with lag screws alone failed at 251.3 (range 66 to 459) N whereas specimens repaired with lag screws and suture anchors failed at 441.6 (range 274 to 661; p = 0.01 N).

CONCLUSIONS

Suture anchor augmentation significantly improved the strength of screw fixation of the calcaneal posterior tuberosity avulsion fractures.

CLINICAL RELEVANCE

The use of suture anchor augmentation as described may improve the reliability of fixation in avulsion fractures of the posterior calcaneal tuberosity.

Calcaneal fractures: what the surgeon needs to know

The calcaneus is an uncommonly fractured bone that plays a critical role in foot biomechanics, weight-bearing, and the ability to wear a shoe. The radiologist acts as a consultant during screening, operative planning, and follow-up imaging of these often complex injuries. Effective communication between radiologist and surgeon requires an understanding of calcaneal anatomy, goals of surgical reduction, and factors that affect patient management and outcomes. In the following pictorial review we will discuss radiologic screening/classification/characterization and their correlation with surgical management and patient morbidity.

Fractures of the calcaneus: a review with emphasis on CT

The calcaneus is the most commonly fractured tarsal bone and accounts for about 2% of all fractures. Advances in cross-sectional imaging, particularly in computed tomography (CT), have given this modality an important role in identifying and characterizing calcaneal fractures. Fracture characterization is essential to guide the management of these injuries. Calcaneal fractures have characteristic appearances based on the mechanism of injury and are divided into two major groups, intraarticular and extraarticular. Most calcaneal fractures (70%-75%) are intraarticular and result from axial loading that produces shear and compression fracture lines. Of the two major systems for classifying intraarticular fractures-Hannover and Sanders-the latter is used most often and is helpful in treatment planning and determining prognosis. Extraarticular fractures account for about 25%-30% of calcaneal fractures and include all fractures that do not involve the posterior facet. The article describes in detail calcaneal anatomy, mechanism of calcaneal injuries and their associated fracture patterns, CT features of intra- and extraarticular fractures, and management implications. Familiarity with calcaneal anatomy and fracture patterns is essential for radiologists to guide the treating physicians.

Avulsionsfraktur der Tuberositas calcanei bei Athleten

Avulsion fractures of the calcaneal tuberosity are rare injuries. Several surgical treatment options have been described. The size of the calcaneal fragment is the limiting factor in choosing the method for restoration. Finding the right type of fixation modality remains challenging in this rare kind of injury. In the case presented one Mitek Super Anchor was used to reattach the small fragment of the tuberosity to the calcaneus. Stable fixation with bony reunion and excellent functional outcome were achieved by this technique within 10 weeks. Therefore, we recommend the use of an anchor system for the treatment of small fragment calcaneal avulsion fractures.

Multislice CT in imaging of trauma of the spine, pelvis and complex foot injuries

Multislice CT (MSCT) has greatly enhanced the performance of CT scanners and has vastly improved imaging of musculoskeletal trauma. Fast, high resolution scanning is now possible. In our institution, MSCT is an essential part of the imaging of the traumatized patient. The advantages of volume imaging, such as multiplanar reconstructions (MPRs) with near isotropic viewing, three-dimensional imaging and thick slice (wedge) MPRs (mimicking conventional radiographs), enable more accurate assessment of complex anatomical areas such as the spine, pelvis and foot. We discuss the general principles of scanning for musculoskeletal trauma and describe our experience of MSCT of the traumatized spine, pelvis and foot.

Displaced intra-articular fractures of the calcaneum: what is new?

The management of displaced intra-articular fractures of the calcaneum remains a contentious subject. Recent advances in the understanding of fracture anatomy have emphasized the fact that not all fractures are the same and therefore different management options should be considered for different patients. This review endeavours to highlight new developments in the assessment of the patient and his fracture and discusses new techniques for the operative management of some injuries. There is also considerable debate on how outcome should be assessed and the role of gait analysis and pedobarography is discussed. Undoubtedly some patients with a displaced intra-articular fracture of the calcaneum will benefit from a surgical procedure the skill, as always, is in deciding which fracture requires which treatment.