Achilles Tendon Ruptures: Operative or Nonoperative (Case with video)Grant
Recently I had the pleasure or working with a 44 year old former collegiate level hockey player following a complete Achilles tendon rupture that was quite an eye opening experience for both of us. Recent research has surprising outcomes when comparing surgical and non-surgical management of acute Achilles ruptures that contravenes conventional wisdom. The following is a brief case outline and highlight of 2 seminal research articles on the topic that has categorically changed my opinion on this nasty injury.
Selected Case Highlights: Our patient is a very active 44 year old athlete who plays hockey twice weekly, personal trains twice weekly, and participates in a spattering of cottage based sport activities. Mid May, while playing basketball, he experienced a ‘pop like someone hit me in the back of my heel with a ball’ while backpedalling.
At the hospital, an orthopaedic surgeon informed him that he had torn his Achilles tendon (ultrasound confirmed) and put him in a plantar flexion (toes down) air boot set at 30 degrees and told our patient to return in 3 weeks to have it adjusted to 15 degrees, then in another 3 weeks to adjust to neutral, then another 3 weeks until removal. He was surprised to hear he was not going to have surgery. Consultation with 2 additional surgeons (one of which was admittedly ‘quick to cut’) both assured him he is not going to require surgery. One also provided him with this paper, which is discussed further below.
I first saw our patient at 3 weeks. He had a positive Thompson squeeze test and a large ‘divot’ palpable in the right lateral (outside) part of his Achilles confirming a tear. After discussion he attended a Sports Medical Doctor for a PRP injection (more on this later) to hopefully aid in the healing process. We will discuss his outcome after looking at the research as promised.
The Research: We will discuss 2 articles for separate reasons:
The first article (Willitis et al 2010) is notable as 2 of the 3 orthopaedic surgeons in our case mentioned this article as justification to treat him non-surgically. This was a 2 centre Canadian (woo-hoo!) study of 144 patients, half of which had surgery, and half of which did not. Those that did not have surgery followed an accelerated functional rehabilitation program (AFRP) linked here. I used this as a general guideline for concepts and timeframes, however the exercises I used were at times altered. After 2 years, there were 2 re-ruptures in the surgical group and 3 in the non-operative group (all in the first 3 months). There was also no difference in strength scores (except 1 for which there was no clear explanation), range of motion, or the size of the person’s calf. Importantly, there were 13 complications suffered in the operative group, and only 6 in the non-operative group. Aside from the re-ruptures, complications in the surgical group included superficial infection (4), deep infection (1), deep vein thrombosis (1) and even a pulmonary embolus (1)!. In fact, 1 of the re-rupture patients had surgery to repair the second rupture and developed a deep infection requiring antibiotics and multiple debridements!
A very recent article from this month’s issue of the American Journal of Sports Medicine is a quantitative systematic review with meta-analysis. Essentially, this type of article groups similar studies together to draw more definitive conclusions. The primary conclusion was that open repair (surgery) had a significantly lower re-rupture rate versus non-operative (3.6% versus 8.8%). However, there was a significant risk of deep infection for the surgical group (2.36% versus 0%) as well as noncosmetic scar complaints, meaning issues such as scar or skin adhesion affecting the tendon which may need to be cleaned up operatively, (13.1% versus 0.62%), and sural nerve disturbance, a sensory nerve near your ankle (8.76% versus 0.78%). Return to work was not significantly different, and strength measures were too varied to draw conclusions.
To sum these findings up in a single sentence: the surgical group had a lower risk of re-rupture, but had a much higher risk of other complications.
So why the difference between the 2 studies? Meta-analyses draw together many more subjects than a single study, which typically makes them better. However, with this come limitations. Here are a few in this particular case:
- The period of cast immobilization was extremely varied between the 7 included studies (from 2-7 weeks for the surgical group and from 2-8 weeks for the non-operative group). The more recent papers included had a more aggressive mobilization protocol, including the Willitis study, and also had closer outcomes comparing the surgical to the non-surgical groups. In my opinion this is the most important limitation. Early mobilization and movement has well documented benefits. Studies showing mechanical loading promotes tendon healing, and recent rehabilitation protocols get the person moving and loading their tissues as early as possible. The difference between this and someone waiting 8 weeks to load the tissue is hard to determine but is likely very important.
- The time to surgery and time to immobilization varied from 3 days to 3 weeks which is huge!
- There were varied rehabilitation protocols that generally were not listed.
So what are our lessons from these papers?
- First and most important: the benefits of functional stimulus to healing of tissue cannot be stressed enough! The Willitis study showed re-rupture of just over 4% for the non-surgical group with the only discernable difference being early active mobilization when compared to previous studies showing up to 13% re-rupture! The bottom line: early range of motion and controlled loading of healing tendons has been shown to result in improved healing over and over.
- In general, it still appears that there is a higher risk of re-rupture for non-operative subjects versus surgical ones, however recent papers stressing early mobilization are beginning to challenge this. Until more are completed however we must reserve our opinion.
- I believe that unless someone is a high level athlete or in an occupation that requires heavy Achilles loading, we will be seeing more and more of these injuries treated non-operatively.
What About Our Patient?:
At 12 weeks, our patient is doing excellent. His muscle girth difference side to side is down to 0.5 inches. His Thompson squeeze test is now negative and there is no longer a palpable ‘divot’. Upon re-attending the Sports Medical Doctor at 9 weeks he was informed that he had never seen such dramatic healing in a non-operative case. What role did the PRP injection play? That’s a topic for our next blog! Enjoy this video of what our NON-OPERATIVE patient is able to do at 12 weeks post complete Achilles rupture.