ARTICLE IN PRESS JID: JINJ [m5G;May 30, 2020;19:10] Injury xxx (xxxx) xxx Contents lists available at ScienceDirect Injury journal homepage: www.elsevier.com/locate/injury Repair of Traumatic Avulsed Achilles Tendon using Double Cerclage Trans-calcaneal Stainless Steel Sutures: Prospective Study and Review of Literature Hossam Hosny b,∗ , Wael Salama b , Ashraf Marzouk b , Mohamed Kenawey a a Orthopaedic Department, Royal Manchester Children’s Hospital, Manchester, UK. b Orthopedic Department, Faculty of Medicine, Sohag University, Sohag, Egypt a r t i c l e i n f o Article history: Accepted 3 May 2020 Keywords: Calcaneus Achilles tendon Repair of tendon avulsion Sleeve avulsion Trans-calcaneal stainless steel sutures a b s t r a c t 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 stain- less 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. © 2020 Elsevier Ltd. All rights reserved. Introduction Achilles sleeve avulsion results in a direct disruption of the triceps surae-calcaneal complex from its insertion. The tendon is avulsed from the posterior calcaneus as a continuous sleeve with- out bony element [1]. Figure 1 It represents a surgical challenge to all orthopedic surgeons as a little tissue is available to facilitate direct repair [2]. When disruption of the achilles tendon results in avulsion of a large bony fragment, it can be managed by open reduction and fixation of the avulsed bony fragment. Methods of fixation include suturing of the avulsed bone fragment, screw fix- ation, tension band wiring and suture anchors [3]. Recent options include screw fixation augmented by suture anchors [4,5] and lock- ing plates in osteoporotic bones [6], but when it is a sleeve avul- ∗ Corresponding author: Orthopedic Department, Sohag University, Sohag, Egypt. E-mail address: hosam09@yahoo.com (H. Hosny). sion injury, the mission is different and difficult. Tendon to bone repair is difficult, challenging and carries bad prognosis [7]. Surgi- cal repair should not only focus on repair of the avulsed tendon but else the surrounding soft tissue structures [8]. Bibbo was the first to use trans-calcaneal suture technique for repairing of this type of injury and it was associated with good functional results [9]. The literature is deficient regarding this type of injury and did not provide a strong and definite treatment. In this study, we will present a new technique for repairing of the achilles sleeve avul- sion injury using double cerclage stainless steel sutures. The tech- nique is not reported before. The new technique is easy, reliable and less expensive than suture anchors. Patients and Methods This is a prospective study. The study was conducted in a ter- tiary level university hospital. All patients were informed about the procedure and agreed to be included in this study. Those patients https://doi.org/10.1016/j.injury.2020.05.010 0020-1383/© 2020 Elsevier Ltd. All rights reserved. Please cite this article as: H. Hosny, W. Salama and A. Marzouk et al., Repair of Traumatic Avulsed Achilles Tendon using Double Cerclage Trans-calcaneal Stainless Steel Sutures: Prospective Study and Review of Literature, Injury, https://doi.org/10.1016/j.injury.2020.05.010