Fractures of the Calcaneal Tuberosity Treated With Suture Fixation Through Bone Tunnels

Authors: Banerjee R, Chao J, Sadeghi C, Taylor R, Nickisch F.

Journal:  Journal of Orthopaedic Trauma

Abstract:  Fractures of the calcaneal tuberosity, although rare, present a challenge for the treating surgeon. The goal of treatment is restoration of function of the gastrocnemius–soleus complex and the Achilles tendon. These fractures often occur in diabetics and elderly osteoporotic patients and therefore fixation of the displaced fragment is difficult. Displaced fractures, if not recognized and promptly reduced, often result in secondary soft tissue compromise. Often, the fragment is a small shell of osteoporotic bone, which is less than optimal for bony fixation. We present our technique for surgical fixation of calcaneal tuberosity fractures using a suture placed through bone tunnels in the calcaneal body. This technique is used by itself for smaller fragments or supplemented with screw fixation for larger fragments.

Keywords: calcaneus fracture, calcaneal tuberosity, calcaneal avulsion

Treatment of Displaced Intra-Articular Calcaneal Fractures with Closed Reduction and Percutaneous Screw Fixation

T. Tomesen, J. Biert and J.P.M. Frölke. 

Journal of Bone and Joint Surgery AM: 2011 May; 93(10):920-8

Surgical treatment of displaced intra-articular fractures of the calcaneus is a standard procedure in many institutions. To avoid soft-tissue complications, several minimally invasive procedures have recently been introduced. The aim of this study was to assess the percutaneous treatment of displaced intra-articular calcaneal fractures with use of one of these techniques.

METHODS:

All patients who underwent percutaneous screw fixation according to the method of Forgon and Zadravecz between 1998 and 2006 were selected. Postoperative infections were recorded. During follow-up, pain, functional outcome, range of motion, and change in footwear were evaluated with the use of the American Orthopaedic Foot & Ankle Society (AOFAS) score and the Maryland Foot Score (MFS). All patients also completed a general health status form (Short Form-36 [SF-36]) and a visual analog scale (VAS) for patient satisfaction. Subsequent subtalar arthrodesis and the removal of irritating screws were performed when indicated.

RESULTS:

We reviewed the cases of thirty-seven patients who had a combined total of thirty-nine displaced intra-articular calcaneal fractures and a follow-up period of at least twenty-four months. Five wound infections occurred, two of which were superficial and three of which were deep. At a mean follow-up time of sixty-six months, the mean AOFAS and MFS scores were 84 and 86 points, respectively, of 100 possible points. The mean score on the SF-36 was 76 points, and the mean score on the visual analog scale for patient satisfaction was 7.9 points of 10 possible points. Twenty-nine patients (78%) were able to wear normal shoes. At the time of follow-up, subtalar arthrodesis had been performed in two patients and seventeen patients (46%) had undergone an uncomplicated removal of painful screws. No substantial correlation was found between the severity of the fracture (Sanders classification) or the quality of the reduction when correlated with functional outcome parameters.

CONCLUSIONS:

We consider the technique of Forgon and Zadravecz to be an excellent option for the treatment of displaced intra-articular calcaneal fractures in selected patients despite the frequent need for screw removal following fracture-healing.

LEVEL OF EVIDENCE:

Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence.

Early Clinical and Radiographic Outcomes after Treatment of Displaced Intra-articular Calcaneal Fractures Using Delta-Frame External Fixator Construct

Charles G. Kissel, DPM, FACFAS 1, Zeeshan S. Husain, DPM, FACFAS 2, James M. Cottom, DPM, FACFAS 3, Ryan T. Scott, DPM 4, Joshua Vest, DPM 5

The Journal of Foot & Ankle Surgery: 50 (2011) 135–140

Intra-articular calcaneal fractures are associated with high morbidity, persistent pain, and long-term disability. This retrospective study assesses early clinical and radiographic postoperative findings of intra-articular calcaneal fractures following treatment by ligamentotaxis using a delta frame construct with a large frag- ment external fixator. Minimally invasive percutaneous reduction of calcaneal fractures is an alternative treatment for Sanders type II, III, and IV fractures. Ten patients from the Detroit Medical Center were followed between January 2002 and December 2004 for follow-up over a mean of 353.5 ` 85.45 days postoperatively. The mean age of the patients was 45.8 ` 12.3 years. There were 2 patients with Sanders type IIA, 3 patients with type IIIAB, 1 patient with type IIIAC, and 4 patients with type IV fracture patterns. The results demon- strated that the mean calcaneal width decreased, the calcaneal height increased, and the calcaneal length increased when comparing preoperative to postoperative measurements. Bo€hler’s angle increased from 20.8 ` 8.27 preoperatively to 25.7 ` 5.21 postoperatively, and Gissane’s angle decreased from 127.4 ` 45.22 preoperatively to 111.2 ` 39.38 postoperatively. The posterior facet step-off on CT examination reduced from 2.6 ` 0.82 mm preoperatively to 0.4 ` 0.26 mm postoperatively. The mean postoperative total subtalar joint range of motion was 19.0 ` 4.5 on the affected side and 34.4 ` 4.58 on the contralateral foot. The mean Maryland Foot score was 85.8 ` 6.41 in the 10 patients. With the exception of the change from preoperative to postoperative Bo€hler’s angle, and the comparison of the ipsilateral (side of the fracture) to contralateral resting calcaneal stance position, all of the comparisons revealed statistically significant (P .05) differences. The authors conclude that the delta frame construct is a viable alternative method to open reduction and internal fixation for treating intra-articular calcaneal fractures.

Level of Clinical Evidence: 4 

Keywords: distraction frame heel ligamentotaxis trauma

1 Detroit Medical Center PM&S-36 Residency Program Director, Detroit, MI 

2 Detroit Medical Center PM&S-36 Assistant Residency Director, Detroit, MI 

3 Submitted during residency, Detroit Medical Center PM&S-36, Detroit, MI 

4 Submitted during residency, Detroit Medical Center PM&S-36, Detroit, MI 

5 Submitted during residency, Detroit Medical Center PM&S-36, Detroit, MI

Stability of Locking and Non-Locking Plates in an Osteoporotic Calcaneal Fracture Model

Till Illert, MD; Stefan Rammelt, MD, PhD; Tim Drewes, MD; Rene Grass, MD

Foot & Ankle International: March 2011 (Vol.32 #3)

Background: The aim of this biomechanical cadaver study of calcaneal

fractures was to investigate whether a locking calcaneal plate provides

more stiffness in osteoporotic bone compared to a non-locking plate.

Materials and Methods: Sixteen fresh frozen bone mineral density

(BMD)-matched cadaver feet were tested in a four-part model of a

Sanders Type IIB calcaneal fracture. The fractures were fixed either

with a non-locking AO (Sanders) plate or an interlocking AO plate

(Synthes, Paoli, PA) to the lateral calcaneal wall with six screws.

Specimens were subjected to cyclic loading which was increased stepwise

to full body weight. Displacement of the posterior facet fragment was

measured with an optical tracking system in the sagittal and transverse

planes. Results: No statistically significant differences were observed

between the non-locking and the locking plates with respect to number

of cycles to failure or 1-mm displacement of the posterior facet. The

initial stiffness was significantly higher for non-locking plates.

Conclusion: In osteoporotic bone, the greater stiffness of the

screw-locking plate construct was offset by the smaller diameter of the

screw threads and the lower friction between the plate and bone when a

locking plate was used. In clinical practice, the plate should first be

compressed to osteoporotic bone with cancellous screws and at least two

screws should be placed in the anterior process and in the tuberosity

of the calcaneus.

Key Words: Calcaneus; Fracture; Locking Plate; Non-Locking Plate;

Biomechanical Properties