SLR - August 2020 - Fasiha Khan

Repair of Achilles Sleeve Avulsion: A New Transosseous Suture Technique

Reference: Yang, Yu-Ping, et al. “Repair of Achilles Sleeve Avulsion: A New Transosseous Suture Technique.” Journal of Orthopedic Surgery and Research, vol. 15, no. 1, 2020, doi:10.1186/s13018-020-01699-2.

Scientific Literature Review

Reviewed By: Fasiha Khan, DPM
Residency Program: VA Puget Sound HCS – Seattle, WA

Podiatric Relevance: Achilles tendinopathy is a common condition seen by Podiatric surgeons and is cited to be the most commonly ruptured tendon in the lower extremity. This affliction is oftentimes accompanied by retrocalcaneal exostoses or enthesophytes, depending on the severity and chronicity of the affliction. Achilles sleeve avulsions are ruptures that occur at the insertional aspect of the Achilles tendon, when there is pre-existing tendinopathy. This is less common when compared to a typical Achilles tendon rupture, which occurs at the watershed area 2-6 centimeters from the insertion point. There is no evidence to suggest that conservative therapies can be fully successful in treating this insertional location of injury due to the avascularity of the fibrocartilage zone, so typically, surgical intervention is preferred. The most commonly used operative technique for repair includes a combination of sutures and anchors, but there is no reported standard method. This study reviews outcomes of 11 cases using a new technique of debriding the calcific tendon and spur, then using the spur stump for drilling and suture fixation to repair the Achilles sleeve avulsion injury. 

Methods: A level IV study was performed on a group of 11 patients diagnosed with Achilles sleeve avulsion injury who were subsequently treated with this novel repair method. The technique included placing the patient prone, removing the avulsed spur, debriding the calcific tendon and any boney exostoses, drilling three holes through the resected bone spur, whip-stitching the Achilles tendon, then passing the ends of the suture through the holes to secure. Outcomes of the procedure were evaluated in terms of the visual analog scale score (VAS), Tegner activity store, and American Orthopedic Foot and Ankle Society score (AOFAS), Victorian Institute of Sports Assessment-Achilles (VISAA) score, Tegner score, and time for return to activity. Secondary factors included pre vs. post-operative MRI findings, ability to perform heel rise, and complications. 

Results: After repair, statistically significant improvement in all scores as noted above were found. Patients were followed for an average of 40 weeks post-op. All patients were able to return to work, daily activities, and sports after 2.8, 3.5, and 12.3 months, respectively. Heel rise tests were performed to the operative side successfully after about 4.5 months. Post-operative MRI studies showed normal continuity of the tendon. No serious complications of delayed wound healing, infection, thrombophlebitis, or re-rupture were noted. 

Conclusions: This new technique is a promising option for repair of Achilles sleeve avulsion injuries. Limitations of the study include small sample size and limited follow up. As this technique led to fewer complications compared to traditional fixation methods, higher-level studies are needed to solidify the benefit of this type of procedure in terms of functional outcomes for the patient.

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