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Avulsion fractures of the calcaneal tuberosity, although relatively uncommon, occur more frequently in patients with osteoporosis and in the elderly. The results of closed manipulation are poor in these fractures, usually requiring open reduction and internal fixation. However, it is difficult to fix the bone fragment rigidly, because the avulsed bone fragment is small and thin, and the bone quality of the calcaneal body in the elderly is poor. Hence, it is necessary to limit prolonged weight-bearing after the operation. We performed an innovative surgical procedure of suture fixation to the anchor screw in four cases, following which earlier postoperative rehabilitation with full weight-bearing walking and range of motion exercises was possible, and bony union was achieved without repeated displacement of the fragment in all patients. We believe this technique would prove useful in surgical management of calcaneal tuberosity avulsion fractures.

Avulsion fractures of the posterior calcaneal tuberosity are rare injuries, and little is known about the underlying factors, outcomes, and prognosis. Furthermore, classifications described previously focus on fracture morphology, with uncertain clinical utility. We present the results of a retrospective study of 21 patients treated for this pathology from January 2002 to December 2015. Features analyzed were age; sex; mechanism of injury; medical comorbidities; type of fracture, as proposed by Beavis; fracture displacement; fragment size; type of treatment; complications; need for secondary surgery; and the American Orthopaedic Foot and Ankle Society score after treatment and follow-up care. Mean age was 56.95years. A total of 61.9% were females, and 71.4% were secondary to low-energy trauma. In addition, 19% were diabetic. Mean follow-up was 57.24 months. Surgery was performed in 81%. Complications rate was 61.9%, and secondary surgery was needed in 38.1%. Mean fracture displacement was significantly higher when complications occurred (25.91mm versus 7.61 mm) (p = .03) and when soft tissues complications appeared (30.65mm versus 14.68 mm) (p = .02). Female gender was associated with the secondary loss of reduction (p = .04). The Beavis classification was not related significantly with any outcome variable. When fracture displacement was ≥2cm, complication rate increased from 30% to 90.9% (p = .008) and soft tissue compromise increased from 0% to 45.45% (p = .035). A new classification system with prognostic value is described, based on fracture displacement. We present 1 of the largest series published to date; fracture displacement is a major variable that influences the outcomes of these injuries, and a new classification attending to a prognostic factor is developed.

Many joint-depressive, neglected calcaneal fractures need distraction arthrodesis of the subtalar joint. Because the calcaneal tuberosity is usually malunited in the varus position, more distraction is required on the medial side to place the tuberosity in the everted position before insertion of a bone graft. Traditionally, a distractor is placed on the medial side to achieve this task. However, the medially placed distractor hinders with the positioning of the extremity and exposure of the main operative site, which is commonly on the lateral side. We introduce a technique to avoid this burden by placing a hinged distractor device on the lateral aspect of the foot while maintaining the correction of the varus deformity.

Calcaneal tuberosity fractures involve the posterosuperior aspect of the calcaneus and may involve the insertion of the Achilles tendon. In this report, we describe an unusual presentation of a calcaneal avulsion fracture involving 2 displaced fragments in a male patient who did not seek treatment for 1 month after the original injury. The larger fragment contained the insertion of the Achilles tendon, and tendon lengthening was required in addition to fixation of the fracture fragments with cannulated lag screws and washers. After reduction and healing, the patient recovered fully without clinical weakness of the triceps surae.