A Novel Technique for the Treatment of Avulsion Fractures of the Calcaneal Tuberosity Victor Chau Hoang DO A. Bae BS, S. Howard DO, J. Hoffman DO, A. Eudy DO, C. Harasym DO, A. Parekh DO, C. Catapano DO, T. Call DO, Theresa Pak DO, Holman Chan MD Valley Hospital Medical Center – Las Vegas, NV Department of Orthopedic Surgery Nevada Orthopedic and Spine Center – Las Vegas, NV
Case Presentation • 72-year-old female presents with a left heel pain after a fall from standing height.
Calcaneal Tuberosity Avulsion Fractures • Rare and uncommon extra-articular injuries (1.3% to 2.7% of all calcaneal fractures.) [1] • Mechanism: Sudden tension on the achilles tendon from falling on a plantar-flexed foot with contracted calf muscles or pushing off a dorsiflexed foot. [2] • Surgery = Gold standard – Restore function of the triceps surae mechanism – Avoid soft tissue complications and skin necrosis.
Issues with O.R.I.F. • Screw fixation - Not always effective to oppose the tension of the achilles tendon • Screw purchase - Often poor making hardware failure a common complication. • Skin necrosis
Issues with O.R.I.F.
Issues with O.R.I.F. Screw pull out
Treatment Goal • A more secure method of fixation to neutralize the deforming forces
O.R.I.F • 5 cm posterior midline longitudinal incision over Achilles tendon insertion • Two 6.5 mm cannulated screws + washers placed anterograde • Achilles tendon sutures and placed deep to the washers and tied around screws. • Tension achilles tendon to the calcaneus.
Solution to Prevent superior migration • Transverse 5 mm x 32 mm cannulated screw adjacent/superior to the two 6.5 mm screws – To get that bone to mat down better – Prevent failure of the other 2 screws from pulling up in the soft calcaneal bone.
Solution to Preventing superior Migration • Suture was shuttled through the screw and tied over the posterior aspect of the achilles tendon footprint • Allowed further approximation • + Achilles tendon lengthening • Release tension on repair.
Post-operative • Patient was placed in a splint • Strict non-weight bearing for 6 weeks. • Patient healed well without wound complications, infection, pain and was ambulating after 6 weeks.
Limitations • Technique not completely minimally invasive • Infection still possible • Case Report
Next Step • Case series • RCT comparing fixation methods
Summary • No consensus on the ideal operative technique for calcaneal tuberosity avulsion fractures • Hardware failure is a common complication. • Novel technique to address these issues.
REFERENCES 1. Beavis, R.C., K. Rourke, and C. Court-Brown, Avulsion fracture of the calcaneal tuberosity: a case report and literature review. Foot Ankle Int, 2008. 29 (8): p. 863-6. 2. ROTHBERG, A.S., AVULSION FRACTURE OF THE OS CALCIS. JBJS, 1939. 21 (1): p. 218-220. 3. Court-Brown CM, Caesar BC. The epidemiology of fractures . In: Rockwood CA, Green DP, Bucholz RW, editors. Rockwood and Green's fractures in adults. Philadelphia: Lippincott Williams & Wilkins; 2006. pp. 95–144. 4. Warrick CK, Bremner AE. Fractures of the calcaneum, with an atlas illustrating the various types of fracture . J Bone Joint Surg Br. 1953;35(1):33–45.
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