A Novel Technique for the Treatment of Avulsion Fractures of the - - PowerPoint PPT Presentation

A Novel Technique for the Treatment of Avulsion Fractures of the Calcaneal Tuberosity

Victor Chau Hoang DO

• A. Bae BS, S. Howard DO, J. Hoffman DO, A. Eudy DO, C. Harasym DO, A. Parekh

DO, C. Catapano DO, T. Call DO, Theresa Pak DO, Holman Chan MD Valley Hospital Medical Center – Las Vegas, NV Department of Orthopedic Surgery Nevada Orthopedic and Spine Center – Las Vegas, NV

Case Presentation

• 72-year-old female presents with a left heel

pain after a fall from standing height.

Calcaneal Tuberosity Avulsion Fractures

• Rare and uncommon extra-articular injuries (1.3% to 2.7%
• f all calcaneal fractures.) [1]
• Mechanism: Sudden tension on the achilles tendon from

falling on a plantar-flexed foot with contracted calf muscles or pushing off a dorsiflexed foot. [2]

• Surgery = Gold standard

– Restore function of the triceps surae mechanism – Avoid soft tissue complications and skin necrosis.

Issues with O.R.I.F.

• Screw fixation - Not always

effective to oppose the tension of the achilles tendon

• Screw purchase - Often poor

making hardware failure a common complication.

• Skin necrosis

Issues with O.R.I.F.

Issues with O.R.I.F.

Screw pull out

Treatment Goal

• A more secure method of fixation to neutralize

the deforming forces

O.R.I.F

• 5 cm posterior midline longitudinal

incision over Achilles tendon insertion

• Two 6.5 mm cannulated screws +

washers placed anterograde

• Achilles tendon sutures and placed

deep to the washers and tied around screws.

• Tension achilles tendon to the

calcaneus.

Solution to Prevent superior migration

• Transverse 5 mm x 32 mm

cannulated screw adjacent/superior to the two 6.5 mm screws

– To get that bone to mat down better – Prevent failure of the other 2 screws from pulling up in the soft calcaneal bone.

• Suture was shuttled through

the screw and tied over the posterior aspect of the achilles tendon footprint

• Allowed further

approximation

• + Achilles tendon lengthening
• Release tension on repair.

Solution to Preventing superior Migration

Post-operative

• Patient was placed in a splint
• Strict non-weight bearing for 6 weeks.
• Patient healed well without wound

complications, infection, pain and was ambulating after 6 weeks.

• Technique not completely minimally invasive
• Infection still possible
• Case Report

Limitations

• Case series
• RCT comparing fixation methods

Next Step

Summary

• No consensus on the ideal operative

technique for calcaneal tuberosity avulsion fractures

• Hardware failure is a common complication.
• Novel technique to address these issues.

REFERENCES

• 1. Beavis, R.C., K. Rourke, and C. Court-Brown, Avulsion fracture
• f the calcaneal tuberosity: a case report and literature review.

Foot Ankle Int, 2008. 29(8): p. 863-6.

• 2. ROTHBERG, A.S., AVULSION FRACTURE OF THE OS CALCIS.

JBJS, 1939. 21(1): p. 218-220.

• 3. Court-Brown CM, Caesar BC. The epidemiology of fractures.

In: Rockwood CA, Green DP, Bucholz RW, editors. Rockwood and Green's fractures in adults. Philadelphia: Lippincott Williams & Wilkins; 2006. pp. 95–144.

• 4. Warrick CK, Bremner AE. Fractures of the calcaneum, with

an atlas illustrating the various types of fracture. J Bone Joint Surg Br. 1953;35(1):33–45.

Thank You