Performing emergency surgery as soon as possible
Beavis et al [14] proposed a classification system for 3 types of calcaneal avulsion fractures: the “sleeve” fracture, the classical “beak” fracture, and the infrabursal fracture from the middle third of the posterior tuberosity [14]. Skin complications due to delayed treatment have also been reported in the literature [10.14.15.16]. Fracture blisters and deep abrasions play an important role in treatment decisions, and their presence often delays the opportunity to operate. In this study, all cases were suffering from varying degrees of closed soft tissue injury. 11(73%) patients underwent emergency surgery. 3/4 of patients underwent elective surgery had their sutures removed at 3 weeks postoperatively, while 8/11 patients underwent emergency surgery had sutures removed at 2 weeks postoperatively. It has shown that the time of suture removal is closely related to whether the emergency surgery is performed. When the fracture displacement shows a local bony bulge, emergency surgery should be performed as soon as possible. However, if an emergency surgery cannot be performed, a plaster fixation in plantar flexion should be used first to avoid soft tissue irritation. Once the surgical conditions are suitable, operation should be done immediately.
Incision selection and soft tissue protection
Displaced posterior calcaneal tubercle fractures, especially Beavis type 2 “beak” fractures, can easily lead to local skin and soft tissue pressure necrosis and the formation of ulcers [17]. Skin blisters and deep abrasions play an important role in treatment decisions, a delay in treatment may lead to serious skin complications. To patients with large fragments, especially for those whose fracture line extend to the subtalar joint, some authors choose the conventional lateral calcaneal plate, but the incision would be larger [16].
In this study, the incision of our procedure was not performed on the heel or on the sole of the foot. We chose a modified, shorter L-shaped incision. The incision was kept at a certain distance to protect the soft tissue from being irritated by the displaced fracture fragment. After reduction of the fracture, the screw at the calcaneal tuberosity was inserted percutaneously, and the skin was sutured using a tension-free technique. No brace was used on the heel within 72 hours after surgery, and the patients were asked to lay their affected limb in a lateral position. 6 patients were delayed in suture removal, mainly because 3 patients were graded as IC-3, and the other 3 patients underwent elective surgery because of other internal diseases. Fortunately, no necrosis or infection of skin and soft tissues were reported.
Strong fixation enables early move and can avoid internal fixation failure.
It is believed that the effect of non-surgical treatment for avulsion fracture of the calcaneal tuberosity is unsatisfactory and open reduction and internal fixation is recommended. There are many studies on the choice of internal fixation for surgery, such as screw fixation, suture anchor fixation, and tension band wiring [14, 18]. Squires et al [7] recommended the use of steel wire and tension bands for fixation. Yoshida et al [19] reported that lag screws were used to fix calcaneal tuberosity avulsion fractures. Cannulated cancellous screws and titanium wire also provided strong internal fixation [16]. Ding Xu [8] presented a technique using a 180-degree microplate and achieved success, but this paper was only a case report. Moreover, complications such as displacement of the avulsed fragment, wound dehiscence, and irritation of the skin have often been reported [10.14.15.16 ]. Laxman Rijal [2] used a Z-plasty of the Achilles tendon and the proximal stump of the Achilles tendon was reinforced with a nonabsorbable polyester suture with a 4.5-mm screw placed transversely in the calcaneus. Fragments were fixed with 4.5-mm cancellous cannulated screws and washers. Before weightbearing, the reinforcement sutures were percutaneously removed under local anesthesia [2]. This process was cumbersome and required multiple operations. Ramanujam CL [21] reported that significant traumatic calcaneal avulsion fractures with concomitant Achilles tendon ruptures can be successfully reduced via the use of Steinmann pins and Ilizarov external fixation. Nevertheless, external fixation devices may prevent patients from living a normal life [21]. Although Agni et al [22] successfully applied LCP hook plate to the avulsion fracture of the calcaneal tuberosity, the plate is too expensive that the financial burden of patients may be increased.
Our technique uses a one-fourth tubular plate made of stainless steel. The plate is thinner than the locking plate and smaller than the ordinary calcaneal plate, therefore, it will cause the least impact on soft tissues. And its price is much cheaper than locking plates. During the operation, the plate is pre-contoured by the assistant to make it appear hook-shaped. The hook-shaped steel plate itself can hook the fragment so that the holding force can be increased to stabilize the fragment. Simultaneously, at the hook, 1–2 screws can be placed in the fragment through the hole on the steel plate for direct compression fixation. In the meantime, apart from the pressure generated by screw, the plate can generate pressure on the fragment surface through the hook. In addition, the operator continues to insert the eccentric screw on the lateral wall of the calcaneus to make the hook fit better. 2–3 screws on the lateral wall can fix the plate and increase the stability of the plate. As a result, there was no loss of reduction or fixation failure in the follow-up. A series of patients had achieved the purpose of early postoperative functional exercise. 15 cases achieved clinical healing at 10.53 ± 1.41 weeks (8–13 weeks) postoperatively. All of them had returned to normal activities.