title: Characterization and Surgical Management of Achilles Tendon Sleeve Avulsions.
abstract: BACKGROUND
  An Achilles sleeve avulsion occurs when the tendon ruptures distally from its calcaneal insertion as a continuous "sleeve." This relatively rare injury pattern may not be appreciated until the time of surgery and can be challenging to treat because, unlike a midsubstance rupture, insufficient tendon remains on the calcaneus to allow for end-to-end repair, and unlike a tuberosity avulsion fracture, any bony element avulsed with the tendon is inadequate for internal fixation. This study aimed to highlight the characteristics of Achilles sleeve avulsions and present the outcomes of operative repair using suture anchor fixation.
  
  
  METHODS
  A retrospective analysis was conducted on 11 consecutive Achilles tendon sleeve avulsions (10 males, 1 female; mean age 44 years) that underwent operative repair between 2008 and 2014. Patient demographics, injury presentation, and operative details were reviewed. Postoperative outcomes were collected at a mean follow-up of 38.4 (range, 12-83.5) months, including the American Orthopaedic Foot & Ankle Society (AOFAS) Ankle-Hindfoot score, visual analog scale (VAS) for pain, plantarflexion strength, patient satisfaction, and complications.
  
  
  RESULTS
  Eight patients (72.7%) had preexisting symptoms of insertional Achilles disease. Ten of 11 (90.9%) injuries were sustained during recreational athletic activity. An Achilles sleeve avulsion was recognized preoperatively in 7 of 11 (64%) cases, where lateral ankle radiographs demonstrated a small radiodensity several centimeters proximal to the calcaneal insertion. Intraoperatively, 90.9% of sleeve avulsions had a concomitant Haglund deformity and macroscopic evidence of insertional tendinopathy. All patients healed after suture anchor repair. The average AOFAS score was 92.8 and VAS score was 0.9. Ten patients (90.9%) were completely satisfied. One complication occurred, consisting of delayed wound healing.
  
  
  CONCLUSIONS
  Achilles tendon sleeve avulsions predominantly occurred in middle-aged men with preexisting insertional disease, while engaged in athletic activity. Suture anchor fixation, combined with addressing concomitant insertional pathology, was a reliable and safe technique for the operative management of Achilles tendon sleeve avulsions. The majority of patients returned to their preinjury levels of work and recreational activity.
  
  
  METHODS
  Level IV, retrospective case series.
authors: Department of Orthopaedic Surgery, Dwight D. Eisenhower Army Medical Center, Fort Gordon, GA, USA jhandyh@gmail.com.
authors: Jeannie
authors: J
authors: Huh
authors: Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA.
authors: Mark E
authors: ME
authors: Easley
authors: Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA.
authors: James A
authors: JA
authors: Nunley
mesh_terms: D000125:Achilles Tendon / Q000503:physiopathology / Q000601:surgery*; D000843:Ankle Joint / Q000502:physiology / Q000601:surgery*; D002111:Calcaneus / Q000601:surgery*; D006801:Humans; D010147:Pain Measurement; D017060:Patient Satisfaction; D012189:Retrospective Studies; D012421:Rupture / Q000523:psychology / Q000601:surgery*; D013536:Suture Techniques; D052256:Tendinopathy / Q000503:physiopathology / Q000601:surgery; D064232:Visual Analog Scale
keywords: Achilles rupture; insertional tendinopathy; sleeve avulsion; suture anchor