Combined Lag Screw and Cerclage Wire Fixation for Calcaneal Tuberosity Avulsion Fractures.


Avulsion fractures of the calcaneal tuberosity represent a rare injury pattern that is caused by a powerful tension force from the Achilles tendon and is usually seen following minor trauma, especially in elderly patients. The objective of this study is to describe a surgical technique using cerclage wiring through cannulated screws in the treatment of extra- and intra-articular avulsion fractures of the calcaneal tuberosity and to present our results in a small patient's cohort. Through a 5.0 cm longitudinal skin incision over the posterolateral aspect of the calcaneus, after adequate debridement of the fracture fragments and while keeping the ankle in plantarflexion, the calcaneal tuberosity is anatomically reduced with the help of a periarticular reduction clamp and an accessory plantar longitudinal approach. Provisionally fixation is performed with K-wires. Definitive fixation is achieved with two parallel partially threaded 7.0 cannulated screws, which are positioned from the superior and posterior aspect of the tuberosity to the inferior and anterior aspect of the plantar surface of the calcaneus, and 1.5 mm cerclage wires that are pulled epiperiosteally to the plantar aspect of the calcaneus to avoid damage to local soft tissues. Alternatively, for smaller fracture fragments, two 3.5 mm partially threaded cannulated screws and 1.25 mm cerclage wires can be used. We also report the results of the procedure in a small cohort of four patients. All fractures healed in an anatomic position. There was no failure of fixation, loss of reduction, or need for secondary surgery, including hardware removal. At final follow-up, all patients had regained full plantar flexion range of motion and strength, with no gait or weight-bearing restrictions. In conclusion, the combination of cerclage wire and large diameter cannulated screws represents a promising option in the treatment of avulsion fractures of the calcaneal tuberosity, demonstrating good functional and radiographic results in our cohort of patients.






Published Version (Please cite this version)


Publication Info

Giordano, Vincenzo, Alexandre Leme Godoy-Santos, Felipe Serrão de Souza, Hilton Augusto Koch, Cesar de Cesar Netto and Stefan Rammelt (2018). Combined Lag Screw and Cerclage Wire Fixation for Calcaneal Tuberosity Avulsion Fractures. Case reports in orthopedics, 2018. p. 6207024. 10.1155/2018/6207024 Retrieved from

This is constructed from limited available data and may be imprecise. To cite this article, please review & use the official citation provided by the journal.


de Cesar Netto

Cesar de Cesar Netto

Instructor in the Department of Orthopaedic Surgery

The desire to explore, research, and understand things in great detail has been the driving force throughout my career. This passion drew me to Foot and Ankle, a subspecialty expanding in orthopedic knowledge with many unsolved mysteries. After completing my Medical School, Orthopedic Residency, and Foot and Ankle Fellowship at the renowned University of Sao Paulo, ranked number one in Latin America for several years, and after five years of clinical practice in Brazil, this desire to explore and understand also brought me to the United States. As part of my Ph.D. program with the University of Sao Paulo, I joined as a visiting scientist and research fellow for Dr. Lew Schon at the traditional MedStar Union Memorial Hospital in Baltimore-MD, where I developed an animal model of induced Achilles tendinopathy. 

As a practicing physician in Brazil, I achieved multiple goals in my early career. Academics have been a large component of my practice, allowing me to participate in young physicians' education and challenge my understanding of orthopedic fundamentals. As the elected Chief of Orthopaedic Residents from 2011 to 2013, I presented 245 lectures to orthopedic surgeons and in multidisciplinary conferences. My practice as an orthopedic surgeon in Sao Paulo allowed me to combine the Brazilian enthusiasm for soccer, serving as the team physician and Foot and Ankle advisor for the professional soccer team Sport Club Corinthians Paulista for almost five years.

As a Foot and Ankle surgeon, I constantly sought to confront the unsolved questions in our orthopedic practices. During my Ph.D. studies with the University of Sao Paulo, I aimed to maximize my research experience and clinical exposure. During my time in Maryland, I have engaged in multiple research projects, collaborating with MedStar Union Memorial and Johns Hopkins University to evaluate and clinically implement innovative imaging techniques, including weight-bearing CT, dynamic CT, 3D MRI, and metal artifact reduction sequence (MARS) MRI.

I was also amazed by the American medical system's resources that create opportunities for motivated physicians to excel in clinical work, educational teaching endeavors, and research investigations. While this balance requires dedication and precise time management, I have been fortunate to work with a variety of mentors who demonstrated to me how great it could be to practice in the US. With that in mind, I ended up deciding to pursue the Academic Pathway of the ABOS Certification. I have completed a total of three Orthopedic Foot and Ankle Fellowships in the US. The first was at the University of Alabama at Birmingham (UAB), the second at the Hospital for Special Surgery (HSS) in New York City, and the third and final at MedStar Union Memorial Hospital in Baltimore-MD. It was a long but very pleasant and rewarding pathway that allowed me to grow as a person, as a clinician, and as a surgeon while being fortunate to create lifetime bonds with several mentors. Once I was done with my fellowships, my objective was to combine my unique background with my innovative and instructive training and apply the acquired knowledge as an Academic Assistant Professor at the Department of Orthopedics of the Carver College of Medicine at the University of Iowa.

The almost four years in Iowa City have been a blast! The leadership of the Orthopedic Department entirely and constantly supported me, and together, we achieved a lot in a relatively short amount of time. I utilized my academic start-up grant to acquire the first Weight-Bearing CT scanner in the Country that allows the hip, knee, foot, and ankle to be scanned under load simultaneously. With the scanner, I founded and served as the Director of the University of Iowa Orthopedic Functional Imaging Research Laboratory (OFIRL), which rapidly achieved an established, recognized position in the research and orthopedic foot and ankle community. I also had the unique opportunity to care for the State of Iowa community suffering from orthopedic foot and ankle problems, always excelling in providing high-quality and passionate clinical and surgical care. I’ll be forever grateful to my leadership, partners, and colleagues in Iowa City, as well as my patients, who gave me the utmost opportunity to care for them.

As an Associate Professor in the Department of Orthopedics at Duke University, I hope to contribute further to the American society and North Carolina Community, taking excellent care of patients, teaching and mentoring medical students, residents, and fellows, and helping the orthopedic foot and ankle surgery research to excel.

Unless otherwise indicated, scholarly articles published by Duke faculty members are made available here with a CC-BY-NC (Creative Commons Attribution Non-Commercial) license, as enabled by the Duke Open Access Policy. If you wish to use the materials in ways not already permitted under CC-BY-NC, please consult the copyright owner. Other materials are made available here through the author’s grant of a non-exclusive license to make their work openly accessible.