Abstract
Background
Calcaneal break avulsion fractures are a challenging pathology seen in foot and ankle surgery. This pathology is typically associated with many unique considerations, including risk of skin necrosis posteriorly and addressing the integrity of the Achilles tendon to curb long-term sequelae. There are a handful of case reports all discussing various ways of treating these fractures, including cancellous screws, lag screws, flexible fixation and tension bending to name a few. Oftentimes there is consideration of excising the fracture fragment, however there are limited reports discussing the utility of reattaching the Achilles tendon in these scenarios. Our case study discusses a calcaneal beak avulsion fragility fracture which was treated with fragment excision and Achilles tendon reattachment.
Methods
We performed a retrospective case review of a single patient who sustained a calcaneal beak avulsion fragility fracture. The case was performed by a single primary surgeon (JM) and co-author of this paper at a single university-based institution.
Discussion
The present case report aims to illustrate an alternative, unique treatment option for the difficult calcaneal beak avulsion fracture. The case discussed provides a good outcome when treated with fragment excision and Achilles reattachment and can be applied to future patients in similar circumstances.
Study Type
Level IV case report
Introduction
Despite only comprising 1–2% of all fractures, the calcaneus is the most fractured bone in the hindfoot and accounts for over 60% of all tarsal fractures. Avulsion fractures make up a smaller subset of less than 3% of all calcaneal fractures, and its incidence increases in women in their seventh decade of life. This is likely due to overall decreased bone mineral density and possible underlying osteoporosis in women of this age. Fragility fractures are typically caused by low energy trauma and occur from either a standing position or lower height. Although these fractures are infrequently encountered, they pose a significant risk to an individual’s mobility and quality of life. Moreover, given the relatively low frequency of this injury, providers may be relatively uninformed about the unique risks that are inherent to this uncommon but often very dangerous fracture. There is some current literature that provides insight into calcaneal insufficiency avulsion fractures in diabetic patients and various methods for treatment. ,,
Avulsion fractures of the calcaneus pose a great challenge to treatment. The Achilles tendon exerts a powerful axial pull onto the calcaneus with repetitive force produced by the gastrocnemius and soleus. This continuous force increases the risk of failure of any fixation methods utilized in this area. Furthermore, the constant pull on the calcaneus by the Achilles poses substantial risk to the integrity of the skin and risk of skin necrosis posteriorly. Several studies have suggested various fixation constructs, including but not limited to suture anchors, Tightrope®, cannulated cancellous screws, titanium wires, tension band wiring, lag screws, or plate fixation. ,,,,,, Calcaneal insufficiency avulsion fractures are caused by repeated stress, usually occurring at the level of the Achilles tendon insertion. Alternatively, fragility factures of the calcaneus occur in patients who sustain low-energy trauma. Both fracture etiologies can occur in individuals with diabetes or osteoporosis. A large majority of avulsion fractures are categorized as type I or “sleeve” avulsion fractures, characterized by the detachment of a cortical shelf from the posterior superior aspect of the calcaneus. Beavis et al. further classified these fracture types, defining type II as “beak” fractures that exhibit an oblique posterior fracture line extending from Bohler’s angle, while Type III or infrabursal fractures involve the middle third of the posterior tuberosity. Rowe et al. classified these avulsion fractures into type II A and B, where type A is a beak fracture, and type B is an avulsion fracture of the Achilles tendon insertion.
At present, there is no consensus regarding the preferred technique for fixating calcaneal beak fractures, especially those resulting from fragility fractures. To our knowledge, this is the first report to discuss calcaneal beak avulsion (Rowe type II) fragility fractures in a non-diabetic patient with a history of osteoporosis. Additionally, we describe a technique tip for complete fragment resection and Achilles tendon reattachment in this patient.
Case report
The patient is a 63-year-old female with a past medical history of seizure disorder and osteopenia who presented to the emergency department with a chief complaint of right ankle pain. The patient stated that she was loading her groceries in her car when she fell back, landing on her right leg. She subsequently experienced immediate pain and discomfort to this area. She denied any head strike or loss of consciousness at the time of her injury. She stated that she had a DEXA (dual energy X-ray absorptiometry) scan in the past which revealed osteopenia and was previously supplemented on Fosamax. At the time of her injury, she was not taking any bone density or vitamin D supplementation. Radiographs in the emergency department revealed a beak (type II) calcaneal fracture that was significantly displaced superiorly, with associated posterior skin tenting ( Fig. 1 ). Clinically, the patient was neurovascularly intact with a posterior calcaneal prominence and associated ecchymosis with notable skin tenting clinically ( Fig. 2 ). The patient was emergently taken to the operating room for surgical intervention in an effort to prevent any skin breakdown or necrosis and associated sequelae.
Lateral plain radiograph demonstrating a beak (type II) avulsion fracture of the calcaneus that is significantly displaced superiorly with skin tenting.
Intra-operative fluoroscopy demonstrating complete resection of the calcaneal fragment.
The patient was placed carefully in a prone position, and attention was directed to the right posterior hindfoot where a midline incision was carefully carried down to the level of the calcaneal fragment. The exposed fracture surface was tenting the skin posteriorly. Given the immense tensile pull of the Achilles tendon on the fragment, it remained flipped posteriorly and was not reducible without Achilles lengthening or other tendon intervention. A decision was made to proceed with excision of the calcaneal fragment and reattachment of the Achilles tendon to alleviate skin tension and restore the integrity of the Achilles, without the risk of re-distraction in the setting of compromised bone quality. The fragment was identified, all soft tissue attachments were carefully reflected, and the Achilles tendon was detached from the calcaneal fracture fragment in its entirety ( Fig. 2 ). The Achilles was reattached to the calcaneus utilizing the Arthrex Speed Bridge system (Arthrex, Inc, Naples, FL) per manufacturing guidelines. The bone tunnels were tapped but not drilled due to the presence of osteoporotic bone. Two 4.25 mm and two 5.5 mm corkscrew anchors were utilized to secure the tendon into the calcaneus, as the bone was quite fragile. Intra-operatively, anesthesia noted that she was extremely resistant to neuromuscular blockade and theorized that this was secondary to her Dilantin therapy. After the repair was complete but prior to closure, the patient spontaneously (forcefully) dorsiflexed her ankle. The anchors were inspected after she was relaxed, and the Achilles remained intact. This was a good, but unexpected, surrogate stress exam. The Thompson test similarly showed intact plantarflexion intra-operatively and lateral fluoroscopic images showed improvement of calcaneal positioning after fragment excision. The incision was then closed in a layered fashion, and the patient was placed in a posterior splint ( Fig. 3 ). She remained inpatient as she awaited post-hospital placement, and during her inpatient stay the splint was exchanged to a short leg cast prior to discharge. She was discharged to a skilled nursing facility for post-operative care due to her fall risk with non-weightbearing status.
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