Treating A Calcaneal Avulsion Fracture In A Patient With Poor Bone Quality

Nicholas J. Bevilacqua, DPM, FACFAS

This author details the surgical treatment of a calcaneal avulsion fracture in a 59-year-old patient with poor bone quality, who later required revisional surgery consisting of excision of fracture fragment and reattachment of the Achilles tendon.

A 59-year-old male presented to the emergency department after injuring his right foot and ankle. The patient described a fall resulting in sudden, forceful dorsiflexion of his ankle. He immediately experienced significant pain on the posterior lower leg along the distal Achilles tendon and posterior calcaneus.

   Clinical evaluation revealed significant alterations in his gait with attempted ambulation. The patient had a palpable bony prominence posterior at the distal Achilles tendon as well as a defect distal to the osseous prominence. The overlying skin was intact and there were no signs of skin necrosis. He had palpable pedal pulses and sensation was intact.

   The exam revealed increased dorsiflexion and weakened plantarflexory muscle strength in comparison to the contralateral limb. There was a positive Thompson test. The resting tension position of the affected foot with the patient lying prone on the table with the knee flexed at 90 degrees was slightly dorsiflexed in comparison to the uninjured side.

   Radiographs revealed a displaced “beak” type calcaneal tuberosity fracture with a fracture line running posterior from just behind the posterior facet.

   His past medical history included coronary artery disease with a history of myocardial infarction. His social history was significant for chronic alcohol use.

A Guide To Surgical Management And Revisional Surgery

After appropriate consultations and medical clearance, the patient went to the operating room. With the patient in a prone position, I performed a posterior midline incision with minimal undermining. Intraoperative findings revealed that the fracture fragment contained the entire insertion of the Achilles tendon. I anatomically reduced the fracture and fixated it with two 4.0-mm partially threaded cannulated screws with bicortical purchase. I used washers because of the poor bone quality. Anatomic reduction occurred with restoration of the normal length-tension relationship of the Achilles tendon.

   I closed the paratenon and skin without tension. To ensure immobility of the affected foot and ankle, we applied a compressive dressing and a posterior splint secured in the gravity equinus position. I transferred him to a skilled nursing facility with strict instructions for non-weightbearing.

   He presented at his two-week follow-up visit without significant pain and discomfort. His incision was well coapted and there were no signs or symptoms of infection. On clinical exam, there was a posterior osseous prominence and radiographs revealed a displaced fracture fragment. The fracture fragment appeared to have pulled through the hardware as the screws did not appear to pull out.

   The patient went back to the operating room for revisional surgery. This was approximately three weeks after the index procedure. At this time, I removed the hardware and noted the comminuted fracture fragment. The bone quality was poor and would be insufficient for fixation.

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