Characterization and Surgical Management of Achilles Tendon Sleeve Avulsions

Magnetic Resonance Imaging Characteristics of a Lateral Ligament Injury in Acute Ankle Sprains Among Athletes

Background

It is important to identify the location and pattern of lateral ligament injuries that are related to the development and prognosis of chronic ankle instability in athletes with ankle sprains.

Purpose

To describe the location and pattern of lateral ligament injuries on magnetic resonance imaging (MRI) in elite-level or amateur athletes with acute ankle sprains and to further assess the risk of associated concomitant injuries.

Study Design

Cross-sectional study; Level of evidence, 3.

Methods

The anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL) of 110 athletes with an ankle lateral ligament injury (mean age, 24.7 years) were evaluated. MRI scans were evaluated for the location and pattern of ATFL and CFL tears such as sleeve avulsions as well as concomitant deltoid ligament injuries, bone contusions, and osteochondral lesions of the talus (OLTs).

Results

On MRI, 52 (47.3%) athletes had an isolated ATFL tear, 56 (50.9%) athletes had both ATFL and CFL tears, and 2 (1.8%) athletes had an isolated CFL tear. ATFL injuries occurred at the fibula, midsubstance, and talus in approximately equal numbers, whereas the majority of CFL injuries occurred at the calcaneal insertion. Concomitant deltoid ligament injuries were identified in 18 (16.4%) athletes. In addition, concomitant bone contusions and OLTs were identified in 38 (34.5%) and 6 (5.5%) athletes, respectively. Using linear-by-linear analysis, CFL injuries correlated with concomitant deltoid ligament and bone injuries (P = .023 and P = .001, respectively) and a sleeve injury pattern (P = .005).

Conclusion

After an acute ankle ligament rupture, almost all athletes involved in this study had injured their ATFL, and approximately 50% had a concomitant injury to the CFL. The rate of sleeve-type CFL injuries at the calcaneal insertion was high, and concomitant deltoid ligament injuries and OLTs were associated with this pattern of injury.

A comparison of characteristics and outcomes of operative treatment for Achilles tendon sleeve avulsion in older versus younger patients

INTRODUCTION

Achilles tendon sleeve avulsion (ATSA) is a rare injury that often results from pre-existing insertional Achilles tendinopathy and occurs when a tendon avulses from the insertion as a continuous sleeve. To date, outcomes of operative treatment for ATSA in older patients have not been reported. Therefore, this study aims to compare the characteristics and outcomes of Achilles tendon (AT) reattachment with or without tendon lengthening for ATSA between older and younger patients.

MATERIALS AND METHODS

This study enrolled 25 consecutive patients who underwent operative treatment following a diagnosis of ATSA between January 2006 and June 2020. The inclusion criterion was a minimum follow-up duration of one year. The enrolled patients were divided into two groups according to their age at operation: ≥ 65 years (group 1, 13 patients) and < 65 years (group 2, 12 patients). AT reattachment was performed in all patients using two 5.0-mm suture anchors after an inflamed distal stump resection in the 30° plantar-flexed ankle position.

RESULTS

The degree of active dorsiflexion and plantar flexion, mean visual analog scale score, and Victorian Institute of Sports Assessment-Achilles scores at the final follow-up were not significantly different between the two groups (P > 0.05 each). The rate of satisfactory clinical outcomes (defined as fair or greater) was 84.6% and 91.7% in groups 1 and 2, respectively.

CONCLUSION

We observed that comparable clinical outcomes could be achieved after AT reattachment with or without lengthening for ATSA between older and younger patients.

Bilateral distal Achilles tendon sleeve avulsion: a case report

BACKGROUND

While Achilles tendon rupture is a common injury sustained especially in sporting events, distal Achilles tendon rupture is less common. Even rarer is a bilateral traumatic distal Achilles tendon sleeve rupture, with outcomes of such injury unknown. The following case report describes this rare injury, not reported to date elsewhere.

CASE

A 57-year-old Finnish man with no predisposing medical history had a traumatic bilateral distal Achilles tendon sleeve avulsion injury. Clinical and radiological evaluation confirmed the diagnosis. Treatment included suture anchors in a modified suture bridge style with customized rehabilitation protocol postoperatively. Symptoms continued to be relieved at 1 year postoperatively.

CONCLUSION

A modified suture bridge style and meticulous rehabilitation protocol including motivated patient contributed to very satisfying results in this very rare bilateral injury.

Comparison of cortical versus cancellous bone fixation in tendon-to-bone healing with a rat trans-calcaneal suture model for Achilles tendon sleeve avulsion

BACKGROUND

Trans-calcaneal suture technique is an economical and effective method for repairing Achilles tendon sleeve avulsion. Whether cancellous bone fixation upon this technique could accelerate tendon-to-bone healing is unknown. The purpose of this study is to compare the effect of cortical versus cancellous bone fixation on tendon-bone healing with a novel rat trans-calcaneal suture model.

METHODS

Trans-calcaneal suture treatment was carried out on the right hindlimb in male Sprague-Dawley rats (N = 80). They were randomly divided into the cortical group (Achilles fixed to the calcaneal cortical bone, n = 40) and the cancellous group (Achilles fixed to the calcaneal cancellous bone, n = 40). Gait analysis and immunohistochemistry were performed 1, 4, 7, and 14 days after the operation. Gross observation, biomechanical analysis, micro-CT, and histological analysis were performed 4 and 8 weeks after surgery. Independent-samples t tests were used for comparison between groups.

RESULTS

At 1, 4, and 7 days, the swing time of the affected limb in the cancellous group decreased, while the duty cycle, the maximum contact area, the print area, and the mean intensity increased significantly. The cross-sectional area of the tendon-bone junction in the cancellous group was smaller, and the failure load and stiffness were higher 4 weeks after the operation. The cancellous group showed more proportion of new bone and a relatively well-organized and dense connective tissue interface with better fibrocartilage-like tissue at 4 weeks after the operation. The ratio of ED2 + macrophages in the cancellous group was significantly higher than in the cortical group on 1, 4, 7, and 14 days. There were no significant differences in gait at 2 weeks, in appearance, biomechanics, new bone formation, and histology at 8 weeks after surgery between the two groups.

CONCLUSION

In the new rat trans-calcaneal suture model, cancellous fixation can accelerate tendon-to-bone healing in the early stage, which perhaps is related to the abundant bone marrow tissue in the cancellous bone that modulates the inflammatory processes.

The Relationship Between Patient Demographics, Tear Locations, and Operative Techniques on the Surgical Treatment of Acute Achilles Tendon Ruptures

Introduction

Achilles tendon ruptures (ATRs) have classically been thought to affect the middle-aged “weekend warrior” participating in basketball, volleyball, soccer, or any ground sport; however, with a more active elderly population, these tears are becoming more common in older patients. We sought to examine the role of demographics, tear location, and operative technique for acute Achilles tendon ruptures treated surgically.

Methods

A retrospective query was performed to identify patients who presented with Achilles tendon ruptures. Inclusion data were primary end-to-end repairs, augmented repairs with flexor hallucis longus (FHL) transfers, augmented repairs with graft, augmented repairs with both FHL transfer and graft use, isolated FHL transfers, and revision Achilles tendon procedures. Demographics and tear locations were collected and analyzed.

Results

Midsubstance tears were the most common tear location occurring in 237 of 286 (82.9%) patients. Distal insertional tears of the Achilles tendon were treated in 35 (12.2%) patients, while 14 (4.9%) patients had a more proximal tear located at the myotendinous junction. Older patients (average age: 53.3±12.5) had significantly more distal insertional tears (p<0.001), while younger patients (average age: 35.1±7.4) presented with significantly more tears at the myotendinous junction (p<0.001). The average BMI was significantly higher (average BMI: 32.2±6.6; p<0.001) in patients with distal insertional tears compared to midsubstance and proximal tears (28.5±4.6 and 28.5±5.3, respectively). There was a higher percentage of diabetic patients who underwent operative treatment for distal insertional tears (20%) compared to midsubstance tears (7.2%).

Conclusion

The findings of our study suggest that a subset of patients, particularly those with advanced age and higher BMI, is more likely to present with a distal Achilles tendon rupture. Additionally, patients in our series who had distal tears more commonly required an augmented repair technique. Our results highlight the need for future research to further define the relationship between increasing age and higher BMI patients sustaining distal tears more often than midsubstance tears.

[Application of percutaneous transcalcaneal reconstruction technique for acute Achilles tendon insertion avulsion]

OBJECTIVE

To introduce a percutaneous transcalcaneal reconstruction technique for the treatment of acute Achilles tendon insertion avulsion, and to assess its short-term effectiveness.

METHODS

Between January 2014 and June 2020, 25 patients with acute Achilles tendon insertion avulsion were treated with the percutaneous transcalcaneal reconstruction technique. There were 24 males and 1 female, with an average age of 44.1 years (range, 34-60 years). The disease duration was 1-5 days (mean, 1.8 days). There were 23 cases of sports injury and 2 cases of fall injury. The preoperative American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score was 55.6±6.7 and the visual analogue scale (VAS) score was 4.6±0.5. The operation time, intraoperative blood loss, hospital stay, related complications, the time of weight-bearing standing with a slightly raised heel, and the time of walking with a slightly raised heel were recorded. The AOFAS ankle-hindfoot score and the VAS score were used to evaluate the ankle joint function and the pain. Achilles tendon continuity was examined by color Doppler ultrasonography and healing of the Achilles tendon was examined by MRI. At last follow-up, the Arner-Lindholm scale was used to evaluate the effectiveness.

RESULTS

The operation time was 45-50 minutes (mean, 46.8 minutes). The intraoperative blood loss was 10-20 mL (mean, 13.8 mL). The hospital stay was 4-6 days (mean, 4.9 days). The color Doppler ultrasonography before discharge showed the continuous recovery of the Achilles tendon. All incisions healed by first intention, and there was no complication such as sural nerve injury or deep venous thrombosis of lower extremity. All patients were followed up 15-50 months (mean, 30.3 months). After 14-21 days, the patients started to weight-bearing stand with a slightly raised heel, with an average of 17.6 days; they began to walk with a slightly raised heel at 20-28 days, with an average of 23.7 days. MRI showed that the Achilles tendon healed at last follow-up. The AOFAS score was 90.0±3.2 at 6 months after operation and 95.8±4.5 at last follow-up, and the VAS scores were 1.7±0.6 at 6 months and 1.0±0.8 at last follow-up, which were all improved when compared with those before operation (P<0.05); the difference was also significant between the two time points after operation (P<0.05). According to the Arner-Lindholm scale, the effectiveness at last follow-up was excellent in 25 cases. All patients had returned to sports.

CONCLUSION

The percutaneous transcalcaneal reconstruction technique is a promising alternative option in treating acute Achilles tendon insertion avulsion, for it can achieve early rehabilitation and better ankle function recovery.

Insertional versus non-insertional tendoachilles tears: a comparative analysis of various predisposing factors and outcome following a repair

BACKGROUND

Association of tendon degeneration, pre-existing posterior heel pain, Haglund's bump, retrocalcaneal spur, and mode of injury varies for the insertional and non-insertional type of tendoachilles tears (TA).

PURPOSE

The study compares the various predisposing factors that determine the distinct type of TA tear and the outcome following a repair.

METHODS

This is a retrospective study of the patients who underwent tendoachilles repair during January 2012-June 2018. Patients above 18 years with a minimum follow-up of two years were included. Patients with calcaneal tuberosity avulsions, prior surgeries, and open injuries were excluded. Patients were divided into groups 1 (insertional tears (IT)) and 2 (non-insertional tears (NIT)), and further subdivided based on the tendon degeneration (as D-degenerative and N-normal sub types) from ultrasound findings. AOFAS score and predisposing factors like degeneration, posterior heel pain, Haglund's bump, spur, and mechanism of injury were compared between the groups.

RESULTS

The study included N = 146 with a mean age of 51.6 years and mean follow-up of 38.6 (range 24 to 96) months. IT associated with degeneration (IT-D) had a trivial fall as the predominant mechanism (P < 0.001). All patients had significant postoperative improvement of scores with no significant difference between the groups (P = 0.59) and subgroups (P = 0.27).75.34% had degenerative tendon, of which 64.5% were in the IT group and the rest in the NIT group (P = 0.02). 51.4% patients had a Haglund bump in the IT group and n.s. (P = 0.9). Forty-seven percent of patients had pre-existing posterior heel pain, 68% in IT and 32% in NIT (P = 0.04). Subgroup analysis revealed 65% of patients were in the IT-D subgroup (P < 0.001).

CONCLUSION

Predisposing factors like posterior heel pain, tendon degeneration, and trivial trauma have a strong propensity for insertional TA tear. In contrast, the prominence of Haglund's bump does not predispose to a distinct type of TA tears. The outcome following a surgical repair-yields good results with no difference between the two groups.

Morphology of Acute Achilles Tendon Rupture by Intraoperative Evaluation

The purpose of this study was to clarify the morphology of acute Achilles tendon rupture (ATR) according to intraoperative evaluation. The morphology of 220 cases was evaluated retrospectively from intraoperative findings from June 2014 to December 2015. We noted 3 characteristics of rupture. First, we divided the ruptures into complete or partial type. Second, according to the level of rupture, we classified them into muscle-tendon junctional type, mid-substantial type, or calcaneal insertional avulsion type. Lastly, on the basis of the pattern of rupture, we divided them into transverse pattern, double-layer pattern, or Z-shaped pattern. All ruptured tendons were repaired with surgical procedures on the basis of the classification of rupture type or pattern. Of the total of 220 cases, 217 were complete ruptures (98.7%) and 3 partial ruptures (1.3%). Regarding the level of rupture, 5 cases were of the muscle-tendon junctional type (2.3%), 209 cases of the mid-substantial type (95%), and 6 cases of the calcaneal insertional avulsion type (2.7%). In terms of the pattern of rupture, there were 198 cases of the transverse pattern (90%), 10 cases of the double-layer pattern (4.5%), and 12 cases of the Z-shaped pattern (5.5%). There was significant gender difference only in the mid-substantial type. Although the morphology of a typical acute ATR was complete, of mid-substance type, and with transverse pattern, other types of ATR were recognized from the intraoperative investigation.

Ultrasonography-Guided Minimally Invasive Surgery for Achilles Sleeve Avulsions

BACKGROUND

Achilles sleeve avulsion, a relatively rare disorder, is characterized by sleeve-shaped injury extending from the calcaneus, located near the tendon insertion site. Unlike midsubstance tears of the Achilles tendon, end-to-end repair is difficult because less soft tissue is preserved distally. Open repair with transosseous sutures or suture anchors is currently favored. The purpose of this study was to evaluate the technical feasibility and functional outcomes of ultrasonography-guided Achilles sleeve avulsion repair.

METHODS

From November 2009 to April 2018, 21 patients with Achilles sleeve avulsions (mean age, 57.8 years; range, 25-82 years) who underwent repair by the same surgeon were retrospectively reviewed. The repair was achieved through a stab wound under ultrasonographic guidance. Two parallel Bunnell-type sutures were crossed over the proximal stump and tied with sutures from suture anchors fixed in the calcaneal tuberosity.

RESULTS

The mean operative time was 44 minutes, and the mean wound size was 1.5 cm. The patients were allowed to walk freely on postoperative week 6 with using high-ankle shoes. At postoperative 2 years' follow-up, the American Orthopaedic Foot & Ankle Society score significantly improved from 70.9 to 97.1 (P < .05); similarly, their 12-item Short Form Health Survey scores improved significantly (P < .05). Only 2 patients had superficial wound infections, which resolved with wound care and oral antibiotics.

CONCLUSION

Our ultrasonography-guided surgical technique for Achilles sleeve avulsions provided excellent soft tissue visualization and availability as well as minimized the wound length to achieve good postsurgical outcomes.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Management of acute Achilles tendon ruptures: a survey of Army orthopaedic surgeons

Background

Despite the literature on acute Achilles tendon ruptures, there remains a lack of consensus regarding the optimal treatment. The purpose of this survey study was to investigate treatment preferences among Army orthopaedic surgeons when presented with a standardized case of an acute Achilles rupture and determine if surgeon factors correlated with treatment preference.

Methods

A hypothetical case of a 37-year-old male with history, physical exam, and imaging consistent with an Achilles rupture was sent to board-certified Army orthopaedic surgeons to determine their preferred management. Demographic data was collected to include: practice setting, years from residency graduation, and completion of fellowship. Correlations analyzed between demographics and treatment preferences.

Results

Sixty-two surgeons responded. 62% of respondents selected surgical intervention. Of these, 59% chose a traditional open technique. 50% of respondents were general orthopaedic. There was a correlation between fellowship training and operative management (P = 0.042). Within the operative management group there was no statistical difference (P > 0.05) in need for further imaging, technique used, post-operative immobilization, length of immobilization, weight-bearing protocol, and time to release to running. The majority of non-operative responders would splint/cast in plantarflexion or CAM boot with heel lift for < 3 weeks (50%) and keep non-weight bearing for < 4 weeks (63%). Only 38% of respondents would use DVT chemoprophylaxis.

Conclusion

When provided with a hypothetic case of an acute Achilles tendon rupture, queried Army orthopaedic surgeons would more often treat with a surgical procedure. This difference in treatment is secondary to training, fellowship or other. This propensity of surgical management, likely stems from the highly active population and the desire to return to duty.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04121-y.

Repair of Traumatic Avulsed Achilles Tendon using Double Cerclage Trans-calcaneal Stainless Steel Sutures: Prospective Study and Review of Literature

INTRODUCTION

Achilles sleeve avulsion results in a direct disruption of the triceps surae-calcaneal complex from its insertion. It represents a surgical challenge to all orthopedic surgeons as a little tissue is available for direct repair of the achilles tendon into its insertion. Methods of fixation include suturing of the avulsed bone fragment, screw fixation, tension band wiring and suture anchors. In this study, we will present a new technique for repairing of the achilles sleeve avulsion injury using double cerclage stainless steel sutures.

PATIENTS AND METHODS

Seven patients with sleeve avulsion of the achilles tendon were included in this study. Only post traumatic cases were involved. Repair of the avulsed tendon using double cerclage stainless steel sutures had been done for all patients. Postoperatively all patients had below knee cast for 4 weeks. Physiotherapy started after cast removal. Patients were followed at 3, 6, 12, 24 months. Pain was measured using VAS score. The AOFAS score was measured at the last follow up.

RESULTS

All patients were followed for at least 24 months. Six males and one female were included in this study. The mean time for returning to work was about 15 weeks. One complication (delayed wound healing) occurred in one patient and healing was well after treatment with antibiotics and continuous dressing. The AOFAS score was excellent for six patients and good for one patient.

CONCLUSION

Double cerclage stainless steel sutures can be used safely to treat patients with achilles sleeve avulsion fracture with a satisfactory clinical outcome.

Ipsilateral free semitendinosus graft with interference screw fixation for surgical management of insertional acute Achilles tendon tears

INTRODUCTION

Very distal tears of the Achilles tendon are uncommon, and poor quality tendinous tissue of the calcaneal stump can compromise healing. Little has been published about the characteristics and surgical management of such injuries. We present a surgical technique, developed by the senior author, to restore continuity of the gastrosoleus-Achilles tendon-calcaneus complex using a free ipsilateral semitendinosus graft, and clinical outcomes of a case series of 28 consecutive patients. Our hypothesis was that this is a safe technique, and patients can return to pre-injury occupation and athletic activities.

PATIENTS AND METHODS

A total of 28 patients (mean age 46 years) underwent minimally invasive reconstruction using a free ipsilateral semitendinosus graft for acute insertional rupture of tendo Achillis. The procedure required two small incisions along the course of the Achilles tendon, and one posteromedial incision at level of the ipsilateral knee to harvest the semitendinosus tendon. Patients were assessed at minimum 2 years (range, 2-2.5 years) following the index procedure.

RESULTS

The median Achilles tendon Rupture Score (ATRS) at the latest follow-up was 88. Two patients developed a superficial wound infection. All patients returned to their preinjury occupation, whilst 22 out of 28 patients (79%), returned to their preinjury level of physical activity at a mean of 6.7 months after surgery, reporting good or excellent overall satisfaction in 88.5% of cases.

CONCLUSION

This minimally invasive technique was safe, and allowed most of patients to return to preinjury daily and sport activities within 9 months from surgery.

Repair of Achilles sleeve avulsion: a new transosseous suture technique

BACKGROUND

Achilles sleeve avulsion usually occurs from pre-existing insertional Achilles tendinopathy, leaving a calcific spur at the insertional site. The purpose of this study was to introduce a new technique using the spur base on the insertional site to drill the suture tunnel to repair Achilles sleeve avulsion.

METHODS

In total, 11 patients diagnosed with Achilles sleeve avulsion underwent this new surgical technique and were followed for a mean time of 40 months. Clinical outcomes were measured using the visual analog scale (VAS), American Orthopaedic Foot and Ankle Society (AOFAS) score, Victorian Institute of Sports Assessment-Achilles (VISA-A) score, Tegner score, and time taken to return to activities. Preoperative and postoperative MRI, the ability to perform heel rise, and complications were also evaluated.

RESULTS

All cases (11/11) had insertional Achilles tendinopathy with calcific spur formation on the tendon's insertion. At final follow-up, the average VAS score improved from 5.3 to 0.1, AOFAS score improved from 44.8 to 97.9, VISA-A score improved from 23.6 to 96.6, and Tegner score improved from 0.9 to 4.9. Tendinopathy symptoms were eliminated. Patients returned to daily activities, work, and sports 3.5 months, 2.8 months, and 12.3months after operation, respectively. Patients took an average of 18.1 weeks after operation to perform the single heel rise test. No severe complications such as infection and rerupture were observed.

CONCLUSION

Our new transosseous suture technique is a promising alternative option in treating Achilles sleeve avulsion. More cases and longer follow up are needed in order to find the best reconstructive option for this pathology.

LEVELS OF EVIDENCE

Level IV.

Repair of Combined Insertional and Midsubstance Achilles Tendon Ruptures

Complex combined tears of the insertion and midsubstance of the Achilles tendon are rare injuries that are challenging to diagnose and treat. The author describes a novel technique for combined insertional and midsubstance Achilles repair that decreases proximal soft tissue dissection, restores musculotendinous length, and directly fixes tendon to bone in a strong, knotless fashion to allow for early mobilization and functional recovery. [Orthopedics. 2020; 43(1):e57-e64.].

Outcomes After Primary Repair of Insertional Ruptures of the Achilles Tendon

BACKGROUND

Achilles tendon insertional sleeve avulsions occur when the Achilles distal tendon sleeve ruptures off of its insertion into the calcaneal tuberosity, sometimes with a small bony fragment from calcific tendinosis. Little evidence exists describing the outcomes and rerupture rate after operative management of Achilles tendon sleeve avulsions.

METHODS

A retrospective chart review was performed to identify patients who sustained an Achilles sleeve avulsion injury treated with operative repair between October 2005 and July 2014. A cohort of 16 patients from the general population and 12 professional athletes were included in the study. The primary outcome variable was rerupture of the Achilles tendon or need for revision surgery. Secondary outcome variables included the Coughlin Satisfaction Scale, visual VR-12, and Foot and Ankle Ability Measure (FAAM).

RESULTS

In the general population cohort, median follow-up was 8.1 years (range, 3.2-11.1 years). The median FAAM Activities of Daily Living score was 100 (range, 42.9-106), and the median FAAM Sports score was 100 (range, 7.1-103.6). The median VR-12 Mental Component Score was 66.9 (range, 45.6-71.8), and the median VR-12 Physical Component Score was 53 (range, 30.8-57.5). In the cohort of professional athletes, preceding insertional Achilles symptoms were present in 91.7% (11/12) of athletes for more than 9 months prior to rupture. All athletes returned to play with an average time of 13.4 months. No patients sustained a rerupture in the follow-up period.

CONCLUSION

Operative repair of Achilles tendon sleeve avulsions was safe and effective with high patient satisfaction and good clinical outcomes in patients from the general population.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

The Acute Injury of the Achilles: Surgical Options (Open Treatment, and, Minimally Invasive Surgery)

Achilles tendon rupture is a common lower extremity injury seen in the active population. Although reruptures rates have improved with nonoperative functional management, surgical treatment is still preferred by the authors. Minimally invasive techniques allow optimal Achilles tendon rupture apposition and tensioning, with a reduced risk of soft tissue complications associated with the traditional open repair.