Tuberosity fractures
Definition
Extra-articular
Low energy injury
- women
- > 70 years
- low bone density - osteoporosis / diabetes
Takahashi et al JBJS Open Access 2024
- 70 patients with calcaneal avulsion fractures
- mean age 69, 67% female
- 20% diabetic
- 20% had osteoporosis
Issues
Achilles tendon attached to piece - non operative associated with poor outcomes
Poor skin at back of heel
Poor bone quality for fixation
Mitchell et al J Orthop Trauma 2019
- 47 patients with calcaneal avulsion fractures
- 45% had open fractures or threatened skin requiring emergent surgery
- 28% implant failure / failure of fixation 3 months after surgery
Xrays
Indications for surgery
Displacement
Threatened skin
Achilles tendon attachment
Approaches
Open
Percutaneous
van der Vliet et al J Foot Ankle Surg 2020
- 58 tongue type fractures
- 33 open reduction: 12% deep infection, revision 3% (1)
- 25 closed reduction: 0% deep infection, revision 16% (4)
Open reduction
Vertical limb of extensile lateral approach
- anterior to tendoachilles
- protect sural nerve
AO surgery reference tongue type calcaneum
Extended lateral approach Vertical limb for tongue type
Percutaneous techniques
Percutaneous incisions
- lateral and anterior to achilles tendon
- at inferior edge of calcaneum
- allows insertion of clamp to reduce fracture
Vumedi tongue-type percutaneous fixation
Options for fixation
Affected by size of fragment / comminution
Screw fixation
Suture anchor / suture bridge construct
Suture button / tightrope
Plate-screw construct
Results
Mitchell et al J Orthop Trauma 2019
- 47 calcaneal avulsion fractures treated with screw fixation
- 11/30 (28%) implant failure / fracture displacement
Takahashi et al JBJS Open Access 2024
- 50 patients with calcaneal avulsion fractures treated with surgery
- 80% treated with screws
- re-operation rate 22%
- infection 14%, necrosis 26%, loss of reduction 18%
- screw fixation alone: re-operation rate 35%
- screw + augementation / washers: re-operation rate 10%
Screw fixation
Poor bone quality
- 2 - 3 screws
- bicortical fixation
- fully threaded screws for extra fixation
- consider washers
Fixation failure with screws
Suture button fixation / Tightrope
Surgical technique suture button PDF
Plate fixation
Indication
Large fragments
Revision
Results
Lou et al BMC Musculoskeletal 2023
- 16 patients with calcaneal tuberosity avulsion
- treated with U plate fixation
- no fixation failure
Technique
Surgical technique U plate fixation PDF