SLR - December 2019 - Sara Yancovitz
Reference: Pi Y, Jiao C, Guo Q. Optimal Outcomes for Acute Avulsion Fracture of the Achilles Tendon Treated with the Insertional Reattachment Technique: A Case Series of 31 Cases With Over 2 Years of Follow-up. The American Journal of Sports Medicine. 2019; 47(12):2993-3001Scientific Literature Review
Reviewed By: Sara Yancovitz, DPM
Residency Program: Grant Medical Center – Columbus, OH
Podiatric Relevance: Avulsion fractures of the Achilles tendon are uncommon conditions and there is a paucity of literature regarding its treatment. This pathology is often considered an end-stage of insertional Achilles tendinitis rather than a calcaneal fracture. Existing research focuses on reattachment of the Achilles at the insertion rather than the calcaneal fracture reduction and fixation. The purpose of this study is to present a retrospective case series to assess the clinical outcomes of an avulsion fracture of the Achilles tendon after a reattachment procedure with reduction and fixation of the calcaneus, and to further identify potential factors predicting post-operative outcomes.
Methods: A retrospective case series was performed including 35 patients with acute insertional rupture of the Achilles tendon who received a reattachment procedure between 2011 and 2017. Lateral ankle radiographs and MRIs were taken pre-operatively and post-operatively for comparison. Each patient underwent a reattachment of avulsed bone of the calcaneus. The Achilles tendon was fixated by either suture anchors or a bone tunnel. If the tendon was too taut, a V-Y lengthening was performed. The ankle was post-operatively immobilized in a short leg cast at 10 degrees plantarflexion for two weeks, then placed in a removable brace allowing passive range of motion. Partial weight-bearing was allowed at six weeks post-operatively with full weight-bearing at 12 weeks post-operatively. Patients were evaluated by their ability to do single-leg heel raises, range of motion at the ankle joint, and subjective outcomes using VAS, AOFAS, FFI, Tegner score and AAS.
Results: From a total of 35 patients, 31 had an average of 43.65 months follow-up. The VAS, AOFAS, FFI, Tegner score, and AAS all showed a significant improvement post-operatively when compared to pre-operative measures. Thirty patients could perform the single-legged heel raise on the operative leg during the post-operative course. Patients with increased body mass were associated with worse post-operative AOFAS and FFI outcomes. Age, preoperative insertional tenderness, Haglund’s deformity and MRI classification showed little association with post-operative outcomes. Surgical complications were limited to 12.9 percent consisting of superficial infections that healed with local wound care and one case of tendon re-rupture.
Conclusions: The reattachment procedure for acute avulsion fracture of the Achilles tendon can achieve firm fixation and promising outcomes. Overall, patients in this study fared well with the proposed insertional reattachment technique for acute avulsion fractures of the Achilles tendons based on objective and subjective measurements. Surgical complications were low. Variables including age, preoperative insertional tenderness, Haglund deformity, and MRI classification showed little association with post-operative outcomes. This study was limited by its case series design evaluating a single surgical treatment and lack of long term follow-up. Further investigation with alternative surgical approaches may provide better insight on the management of acute avulsion fractures of the Achilles tendon.