Treating A Calcaneal Avulsion Fracture In A Patient With Poor Bone Quality
At this point, I decided to excise the fracture fragment and attempt to reattach the Achilles tendon to the remaining calcaneal tuberosity. I debrided the superior surface of the calcaneus noting poor bone quality to the calcaneus. I debrided the distal Achilles tendon and placed a Krakow locking stitch in the Achilles tendon. Contraction of the gastrocnemius-soleus complex made direct re-approximation impossible. I performed a V-Y myotendinous lengthening within the same incision, which allowed for direct re-approximation to the resultant tuberosity without excessive tension.
I subsequently reattached the Achilles to the calcaneal tuberosity using two suture anchors. However, to test the repair, the ankle was dorsiflexed and as a result, the anchors pulled out and the Achilles detached from the bone. At this point, I placed two parallel drill holes through the calcaneus, orienting them posterior-proximal to plantar-distal and leaving a small bone bridge between the drill holes. Using a Keith needle with the suture from the attached distal Achilles, I passed the suture through the bone tunnel (one needle/suture passed through one hole) and the suture exited the skin on the plantar heel. Then I applied tension by pulling the suture and tying the suture ends over a suture button. The button remained outside of the skin and maintained appropriate tension of the Achilles tendon.
I closed the wound in layers and closed the skin without tension. The button was well padded and the patient again wore a compressive dressing and was immobile in a posterior splint placed in gravity equinus.
He returned to a skilled nursing facility and was non-weightbearing. After two weeks, he went home. He was unable to comply with total non-weightbearing status and was ambulating in the controlled ankle motion (CAM) boot. I removed the button in the office eight weeks after surgery and he transitioned to normal footwear. At six months, the patient is weightbearing without issues.
What The Literature Reveals About Calcaneal Tuberosity Avulsion Fractures
Avulsion fractures of the calcaneal tuberosity represent only 1.3 to 2.7 percent of calcaneal fractures. Beavis and colleagues proposed a classification incorporating the three types of calcaneal tuberosity avulsion fractures.1 A type I fracture is a “sleeve” fracture in which one avulses off a shell of cortical bone from the posterior tuberosity. A type II fracture is the classical beak fracture, as I described in this case study. A type III fracture is the infrabursal avulsion fracture from the middle third of the posterior tuberosity. All occur in osteopenic or osteoporotic bone.
Greenhagen and co-workers reported a case of a calcaneal insufficiency avulsion fracture due to Charcot neuroarthropathy in a patient with diabetes.2 Treatment consisted of fracture fragment excision and double row anchor fixation. By removing the fracture fragment, the authors’ proposed method removes pressure on the overlying skin and decompresses the distal posterior compartment. The authors feel that their technique offers inherent advantages to traditional open reduction internal fixation (ORIF).
Bibbo and colleagues described a transcalcaneal suture technique for repair of Achilles tendon sleeve avulsion injuries.3 The authors sutured the Achilles tendon using a modified Bunnell suture and passed the suture through two parallel drill holes in the calcaneus exiting the skin. After excising the skin bridge and tensioning the Achilles tendon, they tied the sutures over the plantar fascia, thereby burying the knot. This technique was very successful in repairing Achilles sleeve avulsions in a variety of patients.