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

Abstract

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 Fixation of Calcaneal Beak Fractures—Biomechanical Analysis of Different Osteosynthesis Techniques

“…Plate fixation was found to be significantly weaker. In calcaneal beak fractures, the skin and soft tissue cover over the heel is at risk and should be handled with great caution ( Banerjee et al, 2012 ; Gitajn et al, 2015 ; Mitchell et al, 2019 ). The advantage of the percutaneous operative technique is the very low risk of soft tissue trauma compared to open techniques.…”

“…The injury itself is usually the result of sudden and disproportional muscular contractions, where the Achilles tendon rips a solid bony fragment out of the tuberosity. These fractures require urgent treatment because the pressure on the thin soft tissue coverage can cause severe necrosis ( Banerjee et al, 2012 ; Mitchell et al, 2019 ). The small osseous fragments in type I and III fractures are typically refixed using suture anchors or transosseous sutures ( Banerjee et al, 2012 ; Wakatsuki et al, 2016 ).…”

Biomechanical Comparison of a Novel 3-Screw Fixation vs Conventional 2-Screw Fixation of Calcaneal Tuberosity Avulsion Fractures

“…3,4,16 Risk factors for these avulsion fractures were reported to be intrinsic gastrocnemius tightness, diabetics, osteoporotic, and elderly patients. 4,5,7,14,15,16-18,21,22 They are challenging to fix because of poor bone stock and an increased risk of fixation failure that is largely contributed by the strong avulsion force of the Achilles tendon. 4,5,7,12,14,15,16-18,21,22…”

“…4,5,7,14,15,16-18,21,22 They are challenging to fix because of poor bone stock and an increased risk of fixation failure that is largely contributed by the strong avulsion force of the Achilles tendon. 4,5,7,12,14,15,16-18,21,22…”

“…Calcaneal tuberosity avulsion fractures are uncommon injuries that pose a high risk of skin compromise. 3,4,5,11,12,[16][17][18] The superiorly displaced tuberosity fragment often tents the skin overlying the posterior heel leading to ischemia and skin necrosis if not managed in an emergent manner. 3,4,5,11,12,[16][17][18] These types of avulsion fracture differed from the more common intra-articular calcaneal fracture because it occurs from the intense contractions of the gastrocnemius-soleus complex during forced dorsiflexion of the ankle with or without trauma.…”