Analysis of Calcaneal Avulsion Fractures Treated Surgically and Nonsurgically: A Retrospective Multicenter Study

Overview

Journal JB JS Open Access

Date 2024 Jul 11

PMID 38988332

Authors

Yu Takahashi

Yasuhiko Takegami

Katsuhiro Tokutake

Yuta Asami

Hidetane Takahashi

Mihoko Kato

Tokumi Kanemura

Shiro Imagama

Affiliations

Soon will be listed here.

Abstract

Background: Calcaneal avulsion fractures (CAvFs) at the Achilles tendon insertion are among the more challenging fractures to treat. Although rare, they often require reoperation. The optimal treatment, including nonsurgical procedures and better implants for surgical procedures in the treatment of CAvFs, remains to be established. Therefore, our study aimed to (1) perform a descriptive evaluation of CAvFs, including cases managed nonsurgically, and (2) assess surgical procedures, including the incidence of complications and reoperation for surgically treated CAvFs.

Methods: In this multicenter retrospective study, we collected data of patients with CAvFs treated at 9 hospitals from 2012 to 2022. We performed a descriptive study of CAvFs and compared postoperative complications and reoperation rates for multiple surgical techniques and implants. The size of the bone fragments was quantified.

Results: The data of 70 patients with CAvFs were analyzed; 20 patients were treated nonsurgically, and 50 were treated surgically. The mean age of patients was 68.5 years; 67% of the patients were female. Nineteen percent of the patients had diabetes, and 19% had osteoporosis. The incidence of postoperative complications was 30%, with infection in 14%, necrosis in 26%, and loss of reduction in 18%. The reoperation rate was 22%. Surgical techniques with use of cannulated cancellous screws were performed in 80% of the surgical cases. Cannulated cancellous screw (CCS) fixation alone resulted in a reoperation rate of 35%, whereas additional augmentation, including washers with CCS fixation, resulted in a reoperation rate of 10%. CCS fixation was successfully performed, although suture anchors were used in some cases with smaller fragments.

Conclusions: CAvFs occurred more frequently in older women and had a high rate of postoperative complications. A combination of CCS with augmentation was more effective at reducing postoperative complications than CCS fixation alone, even when the bone fragment size was small.

Level Of Evidence: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Citing Articles

Analysis of Extreme Beak Calcaneal Fracture (Type 2-Lee) Fixed with Cannulated Cancellous Screws: An Original Research Article.

Kumar V, Kasirajan S J Orthop Case Rep. 2025; 15(1):279-286.

PMID: 39801866 PMC: 11723731. DOI: 10.13107/jocr.2025.v15.i01.5200.

References

Rauer T, Twerenbold R, Fluckiger R, Neuhaus V . Avulsion Fracture of the Calcaneal Tuberosity: Case Report and Literature Review. J Foot Ankle Surg. 2017; 57(1):191-195. DOI: 10.1053/j.jfas.2017.07.016. View

Squires B, Allen P, Livingstone J, Atkins R . Fractures of the tuberosity of the calcaneus. J Bone Joint Surg Br. 2001; 83(1):55-61. DOI: 10.1302/0301-620x.83b1.11184. View

Mitchell P, ONeill D, Branch E, Mir H, Sanders R, Collinge C . Calcaneal Avulsion Fractures: A Multicenter Analysis of Soft-Tissue Compromise and Early Fixation Failure. J Orthop Trauma. 2019; 33(11):e422-e426. DOI: 10.1097/BOT.0000000000001582. View

Banerjee R, Chao J, Sadeghi C, Taylor R, Nickisch F . Fractures of the calcaneal tuberosity treated with suture fixation through bone tunnels. J Orthop Trauma. 2011; 25(11):685-90. DOI: 10.1097/BOT.0b013e3181ffe61e. View

Lui T . Avulsion fracture of the posterosuperior tuberosity of the calcaneus managed with lag screw fixation. Foot Ankle Surg. 2018; 24(1):45-48. DOI: 10.1016/j.fas.2016.11.006. View

Doany M, Garcia A, Komatsu D, Divaris N, Kottmeier S, Paulus M . Avulsion Fractures of the Calcaneal Tuberosity: A Single-Center Review of Outcomes and Complications. J Am Acad Orthop Surg Glob Res Rev. 2021; 5(12). DOI: 10.5435/JAAOSGlobal-D-21-00172. View

Keast D, Bowering C, Evans A, Mackean G, Burrows C, DSouza L . MEASURE: A proposed assessment framework for developing best practice recommendations for wound assessment. Wound Repair Regen. 2004; 12(3 Suppl):S1-17. DOI: 10.1111/j.1067-1927.2004.0123S1.x. View

Khazen G, Wilson A, Ashfaq S, Parks B, Schon L . Fixation of calcaneal avulsion fractures using screws with and without suture anchors: a biomechanical investigation. Foot Ankle Int. 2007; 28(11):1183-6. DOI: 10.3113/FAI.2007.1183. View

Beavis R, Rourke K, Court-Brown C . Avulsion fracture of the calcaneal tuberosity: a case report and literature review. Foot Ankle Int. 2008; 29(8):863-6. DOI: 10.3113/FAI.2008.0000. View

10.

Gardner M, Nork S, Barei D, Kramer P, Sangeorzan B, Benirschke S . Secondary soft tissue compromise in tongue-type calcaneus fractures. J Orthop Trauma. 2008; 22(7):439-45. DOI: 10.1097/BOT.0b013e31817ace7e. View

11.

Jordan M, Hufnagel L, McDonogh M, Paul M, Schmalzl J, Kupczyk E . Surgical Fixation of Calcaneal Beak Fractures-Biomechanical Analysis of Different Osteosynthesis Techniques. Front Bioeng Biotechnol. 2022; 10:896790. PMC: 9386452. DOI: 10.3389/fbioe.2022.896790. View

12.

Voeten S, Nijmeijer W, Vermeer M, Schipper I, Hegeman J . Validation of the Fracture Mobility Score against the Parker Mobility Score in hip fracture patients. Injury. 2019; 51(2):395-399. DOI: 10.1016/j.injury.2019.10.035. View

13.

Hong C, Lim J, Tan J, Pearce C . Outcomes of operatively treated calcaneal tuberosity avulsion fractures. Injury. 2022; 53(3):1276-1282. DOI: 10.1016/j.injury.2021.12.046. View

14.

Hess M, Booth B, Laughlin R . Calcaneal avulsion fractures: complications from delayed treatment. Am J Emerg Med. 2008; 26(2):254.e1-4. DOI: 10.1016/j.ajem.2007.04.033. View

15.

Banerjee R, Chao J, Taylor R, Siddiqui A . Management of calcaneal tuberosity fractures. J Am Acad Orthop Surg. 2012; 20(4):253-8. DOI: 10.5435/JAAOS-20-04-253. View

16.

Ibrahim T, Beiri A, Azzabi M, Best A, Taylor G, Menon D . Reliability and validity of the subjective component of the American Orthopaedic Foot and Ankle Society clinical rating scales. J Foot Ankle Surg. 2007; 46(2):65-74. DOI: 10.1053/j.jfas.2006.12.002. View

17.

Ibrahim D, Swenson A, Sassoon A, Fernando N . Classifications In Brief: The Tscherne Classification of Soft Tissue Injury. Clin Orthop Relat Res. 2016; 475(2):560-564. PMC: 5213932. DOI: 10.1007/s11999-016-4980-3. View

18.

Sugimoto T, Tokutake K, Takegami Y, Okui N, Kanayama Y, Inoue H . Plate fixation through the lateral extensile approach versus cannulated screw fixation through the sinus tarsi approach for calcaneal fracture: a multicenter, propensity score-matched TRON study. Eur J Orthop Surg Traumatol. 2021; 32(7):1333-1340. DOI: 10.1007/s00590-021-03115-9. View

19.

Carnero-Martin de Soto P, Bautista-Enrique D, Gomez-Caceres A, Rodriguez-Leon A, Bravo-Zurita M, Santos-Maraver M . Avulsion Fractures of Posterior Calcaneal Tuberosity: Identification of Prognostic Factors and Classification. J Foot Ankle Surg. 2019; 58(3):423-426. DOI: 10.1053/j.jfas.2018.09.002. View

20.

Harnroongroj T, Tangmanasakul A, Choursamran N, Sudjai N, Harnroongroj T . Measurement technique of calcaneal varus from axial view radiograph. Indian J Orthop. 2015; 49(2):223-6. PMC: 4436490. DOI: 10.4103/0019-5413.152489. View