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.

   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.

In Conclusion

Calcaneal tuberosity fractures represent the end product of an avulsion force as opposed to being the end product of a pure compression force, which occurs in standard calcaneal fractures.4 Therefore, one must neutralize the force of the Achilles tendon when fixating the fracture in order to prevent loss of reduction. Traditional operative treatment of calcaneal avulsion fractures entails ORIF. Other techniques include Steinmann pins, cerclage wire, suture anchors and external fixation.5 Khazen and co-workers proposed augmenting screw fixation with suture anchors to neutralize the pulling force of the Achilles tendon.4

   The case study demonstrates the deforming force of the Achilles tendon on the fixated fracture fragment in a beak type calcaneal avulsion fracture. This case also highlights the poor bone quality that one often encounters when dealing with fractures. I excised the fracture fragment and reattached the Achilles to the calcaneus using a transcalcaneal suture technique. I employed this technique to reattach the Achilles tendon and establish near normal tension of the Achilles tendon in a patient with very poor bone quality.

   Dr. Bevilacqua is a foot and ankle surgeon at North Jersey Orthopaedic Specialists in Teaneck, N.J. He is board certified in both Foot and Reconstructive Rearfoot and Ankle Surgery by the American Board of Podiatric Surgery. He is a Fellow of the American College of Foot and Ankle Surgeons and a member of the American Podiatric Medical Association.


1. Beavis RC, Rourke K, Court-Brown C. Avulsion fracture of the calcaneal tuberosity: a case report and literature review. Foot Ankle Int. 2008; 29(8):863-866.

2. Greenhagen RM, Highlander PD, Burns PR. Double row anchor fixation: a novel technique for a diabetic calanceal insufficiency avulsion fracture. J Foot Ankle Surg. 2012; 51(1):123-127.

3. Bibbo C, Anderson RB, Davis WH, Agnone M. Repair of the Achilles tendon sleeve avulsion: quantitative and functional evaluation of a transcalcaneal suture technique. Foot Ankle Int. 2003; 24(7):539-544.

4. Khazen GE, Wilson AN, Ashfaq S, Parks BG, Schon LC. Fixation of calcaneal avulsion fractures using screws with and without suture anchors: a biomechanical investigation. Foot Ankle Int. 2007; 28(11):1183-1186.

5. Ramanujam CL, Capobianco CM, Zgonis T. Ilizarov external fixation technique for repair of a calcaneal avulsion fracture and Achilles tendon rupture. Foot Ankle Spec. 2009; 2(6):306-308.

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