Calcaneal Avulsion Fractures: A Multicenter Analysis of Soft-Tissue Compromise and Early Fixation Failure.

OBJECTIVE: To characterize the presentation and outcomes of calcaneal avulsion fractures. DESIGN: Case series. SETTING: Two ACS Level I trauma centers. PATIENTS/PARTICIPANTS: Forty-seven calcaneal avulsion fractures isolated from a cohort of 1365 calcaneus fractures treated over a 17-year period. MAIN OUTCOME MEASUREMENTS: We collected instances of soft-tissue compromise at presentation, evidence of implant failure or fracture displacement after fixation, and reoperation. RESULTS: Forty-one patients were treated operatively, and 6 were treated without surgery. Twenty-one patients (44.7%) had either soft-tissue compromise or an open fracture necessitating urgent treatment at the time of presentation. Of those patients treated operatively with 3-month follow-up (n = 39), 28.2% of patients (11/39) had evidence of implant failure or fracture displacement. Age was the only predictor of catastrophic fixation failure (P = 0.01). The use of washer(s), suture anchor(s), or addition of soft-tissue procedures (eg, Strayer) did not have a significant effect on failure rate. Neither the number of screws used nor size of screw impacted the failure rate. Fourteen patients (35.9%) underwent a secondary operation. DISCUSSION: Avulsion fractures of the calcaneus commonly present with soft-tissue compromise and have a significant rate of treatment failure and reoperation. This injury should be identified early and approached thoughtfully, acknowledging that risks are high. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Pathoanatomy of the Tongue-Type Calcaneus Fracture: Assessment Using 2- and 3-Dimensional Computed Tomography.

OBJECTIVE: To define the pathoanatomy of the tongue-type calcaneus fracture and assess the appropriateness of percutaneous techniques in addressing all planes of deformity in this injury. DESIGN: Retrospective cohort. SETTING: ACS Level I trauma center. PATIENTS/PARTICIPANTS: Fifty-six displaced Sanders 2B and 2C tongue-type calcaneus fractures identified from an initial cohort of 1118 calcaneus fractures treated over a 16-year period. MAIN OUTCOME MEASUREMENTS: We reviewed cross-sectional imaging and documented the presence of a varus/valgus (coronal plane) or adduction/abduction (axial plane) position of the tongue fragment in relation to the intact posterior facet, with greater than 10 degrees of angulation being diagnostic of displacement. RESULTS: When assessing for displacement and angulation in the coronal plane, 98% of tongue fragments were either in a position of valgus (77%) or neutral (21%), with a mean valgus angulation of 17.3 degrees. In the axial plane, 98% of tongue pieces were in a position of adduction (64%) or neutral (34%), with an average angulation into adduction of 15.0 degrees. Sanders 2B fractures were more likely to be in a position of valgus and adduction than those of 2C fractures. DISCUSSION: The tongue-type calcaneus fracture most often displaces into a position of plantarflexion, valgus, and adduction. Knowledge of this deformity may aid in achieving successful closed reduction when using the Essex-Lopresti maneuver or other less invasive techniques.

Sarcopenia Is Predictive of 1-Year Mortality After Acetabular Fractures in Elderly Patients.

OBJECTIVES: To determine whether sarcopenia is an independent predictor of mortality in geriatric acetabular fractures. DESIGN: Retrospective cohort. SETTING: American College of Surgeons Level I trauma center. PATIENTS/PARTICIPANTS: One hundred and forty-six patients over the age 60 with acetabular fractures treated at our institution over a 12-year period. MAIN OUTCOME MEASUREMENTS: The primary outcome was 1-year mortality, collected using the Social Security Death Index. We used the psoas:lumbar vertebral index (PLVI), calculated using the cross-sectional area of the L4 vertebral body and the left and right psoas muscles, to assess for sarcopenia. RESULTS: Using a multivariate logistic regression model, we found that low PLVI was associated with increased 1-year mortality (P = 0.046) when controlling for age, gender, Charlson Comorbidity Index, Injury Severity Score (ISS), smoking status, and associated pelvic ring injury. Increasing age and ISS also showed a relationship with 1-year mortality in this cohort (P < 0.001, P < 0.001, respectively). We defined sarcopenia as those patients in the lowest quartile of PLVI. The mortality rate of this cohort was 32.4%, compared with 11.0% in patients without sarcopenia (odds ratio 4.04; 95% confidence interval 1.62-10.1). Age >75 years, ISS >14, and sarcopenia had 1-year mortality rates of 37.1%, 30.9%, and 32.4%, respectively. In patients with all 3 factors, the mortality rate was 90%. CONCLUSION: Sarcopenia is an independent risk factor for 1-year mortality in elderly patients with acetabular fractures. This study highlights the importance of objective measures to assess frailty in elderly patients who have sustained fractures about the hip and pelvis. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.