Does Insertional Reattachment for Acute Sleeve Avulsion Fracture of the Achilles Tendon Provide Sustained Function and Sports Participation?

BACKGROUND

Insertional reattachment of the Achilles tendon is the recommended surgical treatment for acute sleeve avulsion fractures at the tendon insertion in patients fit for surgery and who are comfortable taking the risks associated with the procedure. However, there is a paucity of evidence regarding the longitudinal clinical outcomes and sustained sports participation at minimum 2- and 5-year follow-up after this procedure.

QUESTIONS/PURPOSES

(1) What are the 2- and 5-year patient-reported outcomes after insertional reattachment for acute sleeve avulsion fractures of the Achilles tendon? (2) What proportion of patients return to sports after insertional reattachment for acute sleeve avulsion fractures of the Achilles tendon? (3) What patient factors are associated with inferior patient-reported outcomes, including the VAS, the American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot score, the Foot Function Index (FFI), and Tegner scores, at minimum 5-year follow-up?

METHODS

A retrospective study was performed that evaluated patients who underwent insertional reattachment for acute sleeve avulsion fractures of the Achilles tendon between December 2011 and December 2019 at our institution. During this period, we treated 55 patients for this injury. Surgery was generally offered to patients who presented with acute posterior heel pain and functional loss consistent with insertional rupture, radiographic or MRI evidence of a proximally displaced avulsion fragment, and a Pomeranz classification ≥ Type IB; these criteria were applied consistently throughout the study period. Patients with anesthesia contraindications, immunosuppressive disease, or those who refused surgery were treated nonoperatively and were not included. Five patients met the exclusion criteria, leaving 50 patients, of whom 78% (39) completed both minimum 2- and 5-year follow-up; their results were analyzed in this study. Baseline data were recorded: mean ± SD age was 45 ± 11 years, 92% (36 of 39) of patients were men, mean ± SD BMI was 27.2 ± 2.9 kg/m 2 , 69% (27 of 39) of patients sustained high-energy injuries, 41% (16 of 39) of patients had preinjury insertional pain, and 10% (4 of 39) of patients had prior steroid injection. Patient-reported outcomes (PROs)-including the VAS for pain, the AOFAS Ankle-Hindfoot score, the FFI, and the Tegner activity scale-were collected preoperatively, at minimum 2- and 5-year follow-up. Sports participation, time to return to sport, single-leg heel-rise performance, delayed wound healing, and rerupture were also assessed. A Spearman correlation analysis was used to explore factors associated with minimum 5-year PROs.

RESULTS

Overall, PROs consistently improved and remained improved out to 5 years postoperatively. VAS pain scores improved at 2 years and remained improved at 5 years (4.7 ± 1.3 preoperatively versus 1.6 ± 1.4 at 2 years and 0.7 ± 1.0 at 5 years, mean differences -3.1 and -0.9, respectively; p < 0.001 for both). AOFAS scores improved at 2 years and remained improved at 5 years (50 ± 17 preoperatively versus 88 ± 7 at 2 years and 96 ± 5 at 5 years, mean differences 38 and 8, respectively; p < 0.001 for both). FFI scores improved at 2 years and remained improved at 5 years (110 ± 20 preoperatively versus 11 ± 10 at 2 years and 5 ± 4 at 5 years, mean differences -99 and -6, respectively; p < 0.001 for both). Tegner scores improved at 2 years and remained stable at 5 years (1 ± 1 preoperatively versus 4 ± 1 at 2 years and 4 ± 2 at 5 years, mean differences 3 and 0, respectively; p < 0.001 and p = 0.18). At minimum 5-year follow-up, 64% (25 of 39) of patients were engaged in sports activities, with a mean ± SD time to return to sport of 8 ± 3 months. For those with preinjury sporting demands, 78% (25 of 32) were still participating in sports at minimum 5-year follow-up. In all, 90% (35 of 39) of patients completed a single-leg heel-rise test. Delayed wound healing occurred in 13% (5 of 39), and rerupture occurred in 8% (3 of 39). Increasing age was modestly associated with poorer 5-year Tegner activity score (r = -0.47 [95% CI -0.71 to -0.16]; p = 0.002). A preinjury history of insertional pain was modestly to substantially associated with poorer postoperative VAS (r = 0.32 [95% CI 0.00 to 0.62]; p = 0.047), AOFAS (r = -0.35 [95% CI -0.63 to -0.04]; p = 0.03), and FFI scores (r = 0.52 [95% CI 0.24 to 0.73]; p = 0.001). Similarly, a history of corticosteroid injection was negatively correlated with FFI scores (r = 0.41 [95% CI 0.16 to 0.60]; p = 0.01). Calcaneoplasty performed during surgery was positively correlated with better postoperative AOFAS scores (r = 0.36 [95% CI 0.17 to 0.52]; p = 0.03). No correlations were found between clinical outcomes and other variables.

CONCLUSION

Insertional reattachment for acute Achilles sleeve avulsion fractures yields meaningful and durable improvements in pain, function, and activity level at minimum 2- and 5-year follow-up. Most patients experience continued improvement over time, with stable sports participation at the minimum 5-year follow-up. Importantly, among patients engaged in sports preinjury, nearly 80% maintained sports participation at 5 years, highlighting the durability of this operation. However, a history of preinjury insertional pain and prior corticosteroid injection, features suggestive of underlying tendinopathy, may be associated with poorer minimum 5-year outcomes.

LEVEL OF EVIDENCE

Level III, therapeutic study.