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SICOT e-Newsletter

Issue No. 55 - April 2013

Scientific Debate

A better option? Conservative management for Achilles tendon rupture

Abhishek Kini
Sportsmed Mumbai - Mumbai, India 

The Achilles tendon is the strongest tendon in the human body. It is most commonly injured by sudden plantarflexion while push-off or forced dorsiflexion of ankle beyond its normal range. It almost always suggests a degenerative process within the tendon substance, which signifies an altered and compromised microstructure.

The choice of treatment for Achilles tendon tear has come a full circle with the turn of wheel favoring conservative and operative treatment alternatively with no definite conclusion. The prime argument against operative treatment put forward by the conservative camp is the high rate of post operative complications. The rate of complication in a surgically treated group is as high as 20% in a large study of 775 patients1. These complications include skin necrosis, wound infections, sural neuroma, adhesion of scar to the skin along with the complications associated with anaesthesia.

Skin and wound complications are the most common and most difficult to treat in view of the scarce blood supply around the heel. Another alarming feature is the limited soft tissue coverage options over the tendo Achilles, which more often require microvascular free flaps as split skin grafts do not adhere over an exposed tendon.

Conservative management of Achilles tendon ruptures had been based on long periods of rigid immobilization with above or below knee casts applied with ankle in plantar flexion. These casts were regularly changed with gradual weaning of plantar flexion and progressive increase in weight bearing. Treatment ranged from 12 to 24 weeks and followed by physical therapy2-5. The tendon gap filled with fibrous scar leading to a lengthened tendon which in turn leads to decreased push off. The scarred tendon is also reported to have a higher re-rupture rate5.

This handicap of prolonged treatment has been recently overcome by a functional protocol where the patients are placed in a rigid cast for 3 weeks followed by an ankle-foot orthosis that holds the ankle in 15° of plantar flexion, allowing motion with physical therapy6. Our recent better understanding of tendon healing and its microstructural arrangement has made it possible to modify this even better. Recent evidence has shown that healing tendon when adequately loaded gives the required stimulus to early healing and gets the tendon collagen in orderly fashion, which provides strength to the tendon7.

This functional protocol overcomes the unwanted effects of traditional conservative management, i.e. delayed mobilization, joint stiffness, calf atrophy, reduced push-off strength with a better patient compliance. The strength of healed tendon by this protocol is comparable to surgically repaired tendon and the rate of re-rupture is also similar.

Nowadays, with a better microstructural understanding of tendon healing and its associated pathology (degeneration), are we justified in putting our patients with a tendo Achilles rupture under our knife? This is a question which is open to debate. But with shorter hospital stay, less absenteeism from work, regained levels of strength as surgical patients and lower rate of complications along with lower cost implications on health infrastructure, the favored choice of treatment is functional casting.

References:

  1. Myerson M. Achilles tendon ruptures. Instr Course Lect. 1999;48:219-230.
  2. Maffulli N. Current Concepts in the management of subcutaneous tears of the Achilles tendon. Bull Hosp Jt Dis. 57:152-158, 1998.
  3. Lea RB, Smith L: Non-surgical treatment of tendo achillis rupture. J Bone Joint Surg Am. 1972;54:1398-1407.
  4. Inglis AE, Scott WN, Sculco TP, et al. Ruptures of the tendo achillis: an objective assessment of surgical and non-surgical treatment. J Bone Joint Surg Am.1976;58:990-993.
  5. Cetti R, Christensen S-E, Ejsted, Jensen R. Operative versus nonoperative treatment of Achilles tendon rupture. A prospective randomized study and review of the literature. Am J Sports Med. 1993;21:791-799.
  6. Saleh M, Marshall PD, Senior R, et al. The Sheffield splint for controlled early mobilisation after rupture of the calcaneal tendon: a prospective, randomised comparison with plaster treatment. J Bone Joint Surg Br. 1992;74:206-209.
  7. Virchenko O, Aspenberg P. How can one platelet injection after tendon injury lead to a stronger tendon after 4 weeks? Interplay between early regeneration and mechanical stimulation. Acta Orthop 2006;77:806-12.

Achilles Tendon Rupture: Is Surgical a Better Option than Being Conservative?

Mohd Yazid Bajuri
Universiti Kebangsaan Malaysia Medical Centre - Kuala Lumpur, Malaysia

Many studies have been done on Achilles tendon rupture but there are still controversies surrounding its pathology and treatment. Disagreement occurs especially in finding the best treatment due to similar outcomes either by surgery or conservative treatment.

For me, I am still in favor of surgically managing this common injury despite studies showing higher risk of overall complications. Based on my experience, I found it has much lower risk of re-rupture of the tendon and early return to normal activities as compared to conservative treatment.

Achilles tendon rupture constitutes about 20% of all tendon injuries. It commonly occurs in middle-aged men and usually occurs during sporting activities1. Most of the patients usually have sedentary lifestyles and have just taken up recreational or athletic activities.

The tendon is formed from the combined aponeurosis of the soleus and gastrocnemius muscles. It is the thickest, largest and one of the strongest tendons in the body with an average length of 15cm². The main blood supply comes from the vessels of the paratenon through the short and long vinculae. Thus it creates a watershed area of relatively avascular zone around 2 to 6cm proximal to its insertional point. It corresponds to the commonly rupture site accounting 80% of the cases. Its vascularity is also further compromised during passive stretching and isometric contraction3. The aetiology of Achilles tendon rupture is multifactorial. It is attributed to a degenerative process and mechanical factor. Degenerative changes are also seen following prolonged steroids and fluoroquinolone therapy and systemic diseases such as rheumatoid arthritis, systemic lupus erythematosis and gouty arthritis4,5.

One of the attributed causes is based on the mechanical theory where there is a malfunction of the musculotendinous unit6. Some believe that poor sensory feedback from mechanoreceptors in the ankle joint impairs an individual’s perception of foot position during movement which then leads to eccentric loading of the Achilles tendon6,7.

Achilles tendon rupture is diagnosed mainly from a thorough history and clinical examination. Most are completely asymptomatic prior to the rupture and typically they share similar characteristic features. The mechanism of injury is mostly due to sporting activities such as after sudden accelerating or jumping8. In situations where the clinical findings are equivocal, radiological findings can help in pointing out the diagnosis. Modalities that can be used include ultrasound scan and magnetic resonance imaging (MRI).

An Achilles tendon injury can usually been classified as acute or chronic type. It can be a complete or incomplete injury at the insertion site (4-14%), intertendinous (72-73%), or at the musculotendinous junction (14-24%)9. Acute rupture occurs in a sporting injury in up to 75% of the cases. It is commonly caused by an indirect mechanism rather than direct impact. Direct injuries, however, are more likely to be open. Indirect injury occurs during landing, takeoff, or falling when the foot is forced into dorsiflexion10. Chronic injury occurs when acute rupture is missed or mistreated or when gap appears in the distal part of the tendon and the proximal part is retracted. Chronic injury can also occur as a result of an overuse phenomenon or part of a tendinosis process.

The aims of treatment in an Achilles tendon injury are restoration of normal length and tension and restoring the function of the calf muscle. Traditionally, Achilles tendon rupture was treated conservatively. Surgical treatment gained popularity in the early 1980s as many techniques of repair were invented.

The proponent of operative treatment for Achilles tendon rupture stressed on biomechanical factors to restore the normal length of the musculotendinous unit by closing the tendon gap. The reconstructed site has greater mechanical strength than the scar tissue thus decreasing the rate of re-rupture.

There are advantages to surgical treatment such as early return to work, low re-rupture rate, better calf muscle strength and overall functional outcome. Most recent reviews have recommended surgery as the main treatment11,12 as there is evidence of a reduction in the rate of re-rupture associated with surgery13. Most of the surgeries were performed as an open procedure, although percutaneous techniques have gained popularity14. It is thought that surgically repaired tendons have the benefit of a more rapid rehabilitation. This will lead to an improved muscle function, earlier return to sports and occupational activity. The majority who support surgically managed Achilles tendon rupture do so due to the higher rate of re-rupture after conservative management. In fact, a few studies have reported that the re-rupture rate following conservative treatment is as high as 10-12%, whereas surgery lowers the rate to <3%24.

A recent meta-analysis of randomised trials treatment of ruptured tendo Achilles demonstrated no significant re-rupture rate when comparing conservative to surgical treatment, while offering the advantage of less complications by using functional rehabilitation. The drawback of this treatment is that only certain centres can offer this kind of treatment. However, the report also suggests that surgical repair should be more preferable in centres which do not employ early range-of-motion protocols as it decreases the re-rupture risk in such patients15.

A few studies have reported an earlier time to return to work for the surgically managed patient as compared to conservative treatment20,21. In fact, in a recent meta-analysis it was noted that on average patients whose Achilles tendon rupture was repaired surgically returned to work 19 days earlier than patients who underwent non-surgical treatment15.

Although the functional outcomes between these two treatment modalities are almost similar21,22, at the end of the day, the advantages gained in the surgically managed patients make the surgical option a better choice.

No matter what the treatment choice, a good established rehabilitation program involving physical therapy exercises to strengthen the Achilles tendon and the surrounding leg muscles is the most important factor that determines the long-term outcome. Most of the patients return to their previous level of activity within 4 to 6 months.

References:

  1. Hattrup SJ, Johnson KA. A review of ruptures of the Achilles tendon. Foot Ankle 1985;6:34-8.
  2. DeMaio M, Paine R, Drez D. Achilles tendonitis. Sports Med Rehabil Series 1995; 18: 195-204.
  3. Astrom M, Westlin N. Blood flow in the human Achilles tendon assessed by laser Doppler flowmetry. J Orthop Res 1994; 12: 246-52.
  4. Haines, J. Bilateral rupture of the Achilles tendon in patients on steroid therapy. An Rheum Dis 1983; 42: 652-4.
  5. Zabraniecki L, Negrier I, Vergne P, et al. Flouroquinolone induced tendinopathy: report of six cases. J Rheumatol 1996; 23: 516-20.
  6. Inglis AE, Sculco TP. Surgical repair of ruptures of the Achilles tendon. Clin Orthop 1981; 156: 160-9.
  7. Simoneau GG, Derr JA, Ulbrecht JS, et al. Diabetic sensory neuropathy effect on ankle joint movement perception. Arch Phys Med Rehabil 1996; 77: 453-60.
  8. Jozsa L, Kvist M, Balint BJ, et al. The role of recreational sport activity in Achilles tendon rupture. Am J Sports Med 1989; 17: 338-43.
  9. Lea, Smith L. Non-surgical treatment of tendo Achilles rupture. J Bone Joint Surg 1972; 54-A: 1398-406.
  10. Helal B. Achilles hell (cord). Clin Sports Med 1989; 1: 17-28.
  11. Deangelis JP, Wilson KM, Cox CL, Diamond AB, Thomson AB. Achilles tendon rupture in athletes. J Surg Orthop Adv 2009;18:115-21.
  12. Heckman DS, Gluck GS, Parekh SG. Tendon disorders of the foot and ankle, part 2: achilles tendon disorders. Am J Sports Med 2009;37:1223-34.
  13. Khan RJK, Fick D, Brammar TJ, Crawford J, Parker MJ. Surgical interventions for treating acute Achilles tendon ruptures (review). The Cochrane Collaboration: John Wiley and Sons, 2008.
  14. Gorschewsky O, Pitzl M, Pütz A, Klakow A, Neumann W. Percutaneous repair of acute Achilles tendon rupture. Foot Ankle Int 2004;25:219-24.
  15. Alexandra S, Feroze S, Shahram A, Annette K, Mark G. Surgical versus nonsurgical treatment of Acute Achilles tendon rupture. A Meta-Analysis of Randomized Trials. The Journal Of Bone & Joint Surgery Volume 94-A,Number 23: December 5, 2012
  16. Nyyssönen T, Lüthje P, Kröger H. The increasing incidence and difference in sex distribution of Achilles tendon rupture in Finland in 1987-1999. Scand J Surg. 2008;97(3):272-5.
  17. Hess GW. Achilles tendon rupture: a review of etiology, population, anatomy, risk factors, and injury prevention. Foot Ankle Spec. 2010 Feb;3(1):29-32.
  18. Cary DV. How to diagnose and manage an acute Achilles tendon rupture. JAAPA. 2009 Aug;22(8):39-43.
  19. Molloy A, Wood EV. Complications of the treatment of Achilles tendon ruptures. Foot Ankle Clin. 2009 Dec;14(4):745-59.
  20. Metz R, Verleisdonk EJ, van der Heijden GJ, Clevers GJ, Hammacher ER, Verhofstad MH, van der Werken C. Acute Achilles tendon rupture: minimally invasive surgery versus nonoperative treatment with immediate full weightbearing– a randomized controlled trial. Am J Sports Med. 2008 Sep;36(9):1688-94.
  21. Majewski M, Rickert M, Steinbrück K. [Achilles tendon rupture. A prospective study assessing various treatment possibilities]. Orthopade. 2000 Jul;29(7):670-6. German.
  22. Willits K, Amendola A, Bryant D, Mohtadi NG, Giffin JR, Fowler P, Kean CO, Kirkley A. Operative versus nonoperative treatment of acute Achilles tendon ruptures: a multicenter randomized trial using accelerated functional rehabilitation. J Bone Joint Surg Am. 2010 Dec 1;92(17):2767-75.
  23. Möller M, Movin T, Granhed H, Lind K, Faxén E, Karlsson J. Acute rupture of tendon Achillis. A prospective randomised study of comparison between surgical and non-surgical treatment. J Bone Joint Surg Br. 2001 Aug;83(6):843-8.
  24. Kocher MS, Bishop J, Marshall R, Briggs KK, Hawkins RJ. Operative versus nonoperative management of acute Achilles tendon rupture: expected-value decision analysis. Am J Sports Med. 2002 Nov-Dec;30(6):783-90.