Management of Calcaneal Insufficiency Fractures

Ellianne M. Nasser, DPM, CWS, FACFAS Diplomate, American Board of Podiatric Medicine Associate, Podiatry Site Director, Podiatry, Geisinger Community Medical Center Program Director, Podiatric Medicine and Surgery Residency Geisinger Community Medical Center Calcaneal Insufficiency Fractures

• DM

• Long term steroid use

•

• Renal failure/HD

• RA

• Radiotherapy

• Celiac Disease Calcaneal Fracture Management in DM

• Focus on avoiding major complications/ fx stabilization

• Most literature extrapolated from DM ankle fx ñ HbA1c ñ Prolonged immobilization

• Avulsion fx of tuberosity: 1.3- 2.7% of all calcaneal fx

• Ex-Fix

• OM Risk Factors for Complications in DM

• Peripheral neuropathy

• Surgery duration

• HbA1c>7 ñ Shibuya et al 2013 ñ 165 DM arthrodesis/osteotomy/ORIF

• HbA1C in diabetic ankle fractures ñ Poor radiological outcome, revision, complications, higher with HbA1c>6.5 ñ Liu et al 2013 ñ 21 DM ankle ORIF Infection

• 25% wound complication rate in 190 calcaneal fractures ñ Smoking, , open injuries ñ Folk et al

• Double layer closure less wound complications ñ Abidi et al Low Energy Injury, Insufficiency Fracture? Calcaneal Insufficiency Fracture after Ipsilateral TKA Jeong et al 2016

3 months s/p TKA 1 month later Casted 3 months heel pain no trauma Calcaneal Insufficiency Fx Secondary to Celiac Disease – Induced Osteomalacia Kose et al 2015

• 33yo F Celiac Disease

• Heel pain x 2 months

• Treated as

• After 3 months Scan/MRI

• NWB 4 weeks

• Vit D supplementation

• Compliance with gluten free diet Calcaneal Insufficiency Avulsion (CIA) Fractures Kathol et al 1991

• 61 calcaneal fx  21 DM

• Non DM – no CIA, no spontaneous fx

• All DM insulin dependent >5 years + PN

• 14 calcaneal insufficiency avulsion fractures ñ 9/14 h/o ulcer, 4 in ipsilateral extremity ñ Mean age onset of DM: 14.6 ñ Mean age fx 34.8 Calcaneal Insufficiency Avulsion (CIA) Fractures: Mechanism? Kathol et al 1991 • Microfractures

• Compound to become undisplaced insufficiency fx 6 weeks after pain initiated • Fragmentation/ secondary fx line

• Dorsal displacement of fragments

X-ray for hallux ulcer Pain to heel x 1 week When ORIF fails… Biehl et al 1993 Calcaneal Fractures in Diabetic Patients – 3 basic fracture types: Hedlund et al 1998

• 25 year period, hospital records searched: 21 diabetic calcaneal fx

• All but 1 IDDM

• No major trauma prior to injury

• 15 on long term, high-dose steroids

• 18 poor renal function or renal failure

• 9 patients had decreased WB in the 9 months preceding fx

• “significant deformity” in half of patients at f/u Type 1: Avulsion Fractures Type 2: Mid- calcaneal compression fx Type 3: “Wedge” Fracture DM Calcaneal Insufficiency Fx Greenhagen et al 2012

• 39yo IDDM

• Charcot contralateral extremity in CAM for ulcer offloading

• Heel pain x 2 weeks

• Immobilized

• 6 weeks later “trips”

Open Calc Fx in Diabetic Patients with Neuropathy Athans and Stephens 2008 Case 1

• 43yo M

• DM2 x 10 y

• 20py smoking

• 6 mo ulcer

• Gas under calc

• IV abx, debridement

• BKA Case 2

• 44yo M

• DM2 x 16y

• Nonsmoker

• h/o liver/kidney transplants

• Ulcer x 4 mo

• Partial calcanectomy, IV abx

• Plastics – free muscle flap

• 4 years community ambulator with AFO Case 3

• 43yo F

• DM1 x 19 yrs

• Nonsmoker

• G3 ulcer with OM x 1 mo

• IV abx, I&D, partial calcanectomy

• Dehiscence of surgical site

• 4 years community ambulator AFO Theories?

• Abnormal gait, increased pressure under met heads

• Increased stiffness of in diabetics

• Additional tension on achilles tendon  calc fx Pathologic Fractures of the Calcaneus Secondary to Osteomyelitis: A Case Series Brucato, Wachtler, Nasser 2016

• 5 pts, DM (+) neuropathy

• All pts with previous heel ulcer

• All cases OM diagnosed by bone bx or MRI prior to fx

• avg time OM present 103 days

• All pts tx with IV abx and partial calcanectomy

• 1 pt healed ulcer

• 3 BKA

• 1 expired with ulcer still present Case 1

• Ulcer x 2 mo

• OM x 30 days • Resection of fx fragment

• F/u MRI persistent OM

• s/p total calcanectomy Case 2 • OM x 165 days • Open fx calc • Resection fx fragment with achilles reattachement

• Ulcer present at time of expiration Case 3 ñ OM x 95 days ñ Open fx calc • Failed ex-fix

• Resection fx fragment Case 4 ñ OM x 130 days ñ Bone bx (+) • Percutaneous 8.0 screw

• Ulcer healed at 52 weeks Case 5 ñ OM x 80 days ñ (+) bone bx ñ Fx resection with achilles reattachment • TTC fusion

• Plate removal, ex-fix Case 1: 48yo DM

• 4 year history of heel ulcer/fx

• h/o “multiple surgeries,” PICC

• HH, ambulating in CAM

• No bone exposed initial visit

• DM + neuropathy

• A1C 11.4

• TCC • s/p debridement, TAL

• PICC IV Vanc

• Finally agreed to BKA Case 2: 56yo DM

• DM + neuropathy

• HbA1C 8.1

• Left TMA 2016

• Treated for B/L heel ulcerations

• R heel ulceration x 2 months

• Noncompliant

• OR for debridement/bone bx

• (+) OM to calc

• Group B strep/ enterococcus

• IV Vanco + PO Cipro per ID

• Continued noncompliance

• BKA after 2 months Case 3: 60yo F

• DM + neuropathy, PAD

• HbA1C 11.6

• Wound x 2 months

• Recent debridement/bone bx with Plastics

• (+) OM calc

• Initial consult WBC 33

• 3 months prior ambulating and working 2 jobs

Case 4: 41yo F

Conclusion: surgical options?

• Calcanectomy

• Soft tissue coverage?

• ORIF

• Ex-Fix

• BKA References • Athans W, Stephens H. Open calcaneal fractures in diabetic patients with neuropathy: a report of three cases and literature review. Ankle Int 29(10): 1049-1053.

• Biehl WC 3 rd , Morgan JM, Wagner FW Jr, Gabriel R. Neuropathic calcaneal tuberosity avulsion fractures. Clin Orthop Relat Res. 1993(296)8-13.

• Burns P, Highlander P, Shinabarger B. Management in high-risk patients. Clin Pod Med Surg 31:523-538, 2014.

• Fuduka T, Reddy V, Ptazek AJ. The infected calcaneus. Foot Ankle Clin N Am 15:478-486, 2010.

• Greenhagen RM, Highlander PD, Burns PR. Double row anchor fixation: a novel technique for a diabetic calcaneal insufficiency avulsion fracture. J Foot Ankle Surg 51:123-7, 2012.

• Hedlund LJ, Mki DD, Griffiths HJ. Calcaneal fractures in diabetic patients. Journal of Diabetes and its Complications 12:81-87, 1998.

• Kathol MH, El-Khoury GY, Moore TE, et al. Calcaneal insufficiency avulsion fractures in patients with diabetes mellitus. Radiology 1991; 180:725-9.

• Sagray BA, Stapleton JJ, Zgonis T. Diabetic calcaneal fractures. Clin Pod Med Surg 30:111-118, 2013.

• Wachtler MF, Brucato MP, Patel K. Pathologic fractures of the calcaneus secondary to osteomyelitis: a case series. ACFAS Poster 2013.