The low incidence of the avulsion f

The low incidence of the avulsion fractures of the posterior calcanealtuberosity is the reason why little is known about these fractures. Themechanism and pattern of injury differ from intra-articular calcaneal fractures, but few descriptive series have been published. We hereby present,to our knowledge, the second longest series published about this injury.Typical presentation of the fracture in our series was a female patientin the sixth decade of life who suffered low-energy trauma. Surgery wasoften needed, and complication rate was 61.9%, with the secondary lossof reduction and soft tissue compromise being the most frequent. Thesefindings are similar to those registered in the longest series published(13), whereas other authors reported a higher frequency in young malessuffering high-energy trauma (12). There is a general trend to describethese fractures as osteoporotic insufficiency fractures (2,3,16). Becausethey have been usually observed in patients over the sixth decade of life,it is logical to conclude that low bone quality plays a major role. however,they can also occur after a high-energy trauma. Diabetes has also beenassociated with these fractures and with complications after treatment(16,17). Secondary diabetic neuropathy can cause decreased pain sensation at the heel and, therefore, leave it more susceptible to repeatedmicrotrauma that can facilitate the fracture (3). In our series, the prevalence of diabetes was as high as 19%, which remarks the importance ofthis pathology in the development of the injury.Need for the secondary surgery varies in the literature from 20% to36.3% (13,18), similar to our series (38.1%). Most common causes wereretroaquileal bursitis, secondary loss of reduction, and soft tissue complications. It is interesting to remark that only medical comorbiditiessuch as hypothyroidism, peripheral vascular disease, and the presenceof >1 comorbidity have been identified as predictors of the need forthe secondary surgery (13).