PMC5759099_01
Lateral x-ray of the original fracture.
TOORTHJ-11-1568_F2.jpg
PMC5759099_01_TOORTHJ-11-1568_F2.jpg
F2
X-rays confirmed an avulsion fracture of the heel at the insertion of the Achilles tendon Fig. (2).
Lateral x-ray after open reduction and internal fixation of avulsed fragment.
TOORTHJ-11-1568_F3.jpg
PMC5759099_01_TOORTHJ-11-1568_F3.jpg
F3
Postoperative x-rays demonstrated adequate reduction of the fracture (Fig. 3).
Skin necrosis and infection after re-fracture.
TOORTHJ-11-1568_F4.jpg
PMC5759099_01_TOORTHJ-11-1568_F4.jpg
F4
The skin around this necrotic area had the clinical appearance of infection, though we were unable to determine whether it was a local or a deep infection (Fig. 4).
Removed bone fragment.
TOORTHJ-11-1568_F5.jpg
PMC5759099_01_TOORTHJ-11-1568_F5.jpg
F5
The bone fragment was removed together with the screw used for the initial osteosynthesis Fig. (5), but the attached part of the Achilles tendon was preserved and re-attached to the calcaneous tuberosity using two anchor sutures Fig. (6).
Plaster cast applied after debridement and tendon reattachment.
TOORTHJ-11-1568_F7.jpg
PMC5759099_01_TOORTHJ-11-1568_F7.jpg
F7
The wound was inevitably left uncovered; a full plaster cast was applied, with the leg in plantar flexion and a posterior window to allow observation of the wound on a daily basis (Fig. 7).
Wound before final coverage, eight weeks post op.
TOORTHJ-11-1568_F8.jpg
PMC5759099_01_TOORTHJ-11-1568_F8.jpg
F8
The size of the skin lesion was reduced to 2x2 cm and the depth of the deficit was less than 1 cm (Fig. 8).
Complete, stable coverage, ten weeks post op.
TOORTHJ-11-1568_F9.jpg
PMC5759099_01_TOORTHJ-11-1568_F9.jpg
F9
Two weeks later, the flap and 90% of the grafts had survived, the Achilles tendon was at that time completely covered (Fig. 9) and the patient was put on a removable dynamic brace that allowed ankle mobilization and gradual weight bearing.
Final functional outcome, three months post-op.
TOORTHJ-11-1568_F10.jpg
PMC5759099_01_TOORTHJ-11-1568_F10.jpg
F10
Finally, 12 weeks after skin excision and tendon re-attachment the skin was completely healed, the patient had restored her right ankle motion (plantarflexion of 35 degrees and dorsiflexion of 15 measured with a goniometer) and was able to perform a single heel rise (Fig. 10).