Conservative And Surgical Treatment Of Achilles Tendon Ruptures

When patients present with various pathologies, I try to give a frank assessment of their situation and treatment options so that they can make an informed decision. Sometimes, a decision can be difficult for patients despite fully understanding their situation. I am often reminded of a quote from one of our profession’s great educators, Dr. Irv Kanat, who I only briefly had a chance to get to know. He would preach, “Treat patients how they want to be treated. Not how you would want to be treated.” I try to put myself into the patient’s position and factor in lifestyle and expectations before giving them my opinion if I notice a decision-making struggle. In my experience, this is the essence of informed consent. One scenario where the outcome results have become more difficult to differentiate is in dealing with Achilles tendon ruptures.

Achilles tendon ruptures, commonly seen in the active population, have no associated consensus on whether such tears require surgical treatment. The incidence of Achilles tendon ruptures is 18:100,000 per year and occur more commonly in men aged 30 to 40 years.^1,2 Studies show that 60 percent of Achilles tendon ruptures are sports-related.³ Fluoroquinolones have been associated with tendon ruptures in patients who have renal dysfunction.⁴ Histopathologic studies show that ruptured Achilles tendons have tissue and cell necrosis, calcification, irregular and degenerated collagen fibers around the rupture site.⁵ Surgical options for the treatment of Achilles tendon ruptures include end-to-end Achilles tendon repair and percutaneous or mini-open Achilles tendon repair. Furthermore, augmentation to the repair may also include V-Y advancement (Figure 1) or FHL tendon transfer (Figure 2). There is a growing body of research in support of functional rehabilitation for non-surgical treatment of acute Achilles tendon ruptures.^6,7 Recommendations on how to treat acute Achilles tendon ruptures has become controversial and requires an open dialogue with the patient and family to make the best decision for the situation.

Minimizing the re-rupture rate and improving functional outcome should be the goals when considering treatment options. A review of 762 patients with Achilles tendon ruptures showed that 14/381 (3.7 percent) surgically treated patients and 37/377 (9.8 percent) non-surgically treated patients re-ruptures.8 No statistical significance was found in the incidence of deep vein thrombosis (DVT), ankle joint motion or time to return to sport. One drawback of the study was the limited time of follow-up that only averaged 15.4 months.⁸ Future studies should be double-blinded randomized-controlled trials with long-term follow-ups.

Other studies show re-rupture rates in surgically treated Achilles tendon ruptures between 3.5 and 4.3 percent and 8.8 to 9.7 percent in non-surgically treated Achilles tendon ruptures.⁹ Conservative treatment also avoids common surgical complications including wound infection, sural nerve injury and scar adhesion. A cohort study found non-surgical management of Achilles ruptures with a gap greater than 10 mm resulted in higher rates of re-rupture then the ones treated conservatively with a gap less than 10 mm.10 With larger gaps, studies do show surgical intervention is superior, however more research is necessary to access how well patients do with conservative treatment when addressing complete ruptures less than 10 mm.¹⁰

Evaluation of surgical and conservative outcomes of Achilles tendon ruptures does demonstrate some differences. Jiang and colleagues performed a meta-analysis including ten random-controlled trials with a total of 894 patients from 1980 to 2011.¹¹ In the end, no significant difference was evident when comparing surgical and non-surgical management of Achilles tendon ruptures in regards to successful return to pre-injury sports and vein thrombosis events. Surgical patients did have shorter time for sick leave and better re-rupture rates.¹¹

Brumann and team reviewed five trials that compared full immobilization and immediate full weightbearing following acute Achilles tendon tear repairs.¹² Overall, the authors found early ankle mobilization led to shorter time to return to work and sports, higher satisfaction rates, early return to pre-injury activity levels and reduced muscle atrophy. More importantly, there was no increase in the rate of re-rupture with more aggressive mobilization. The authors also advocated that controlled ankle mobilization by free plantarflexion and limited dorsiflexion at zero degrees is applicable after the second postoperative week.¹²

In contrast, functional rehabilitation for non-surgical treatment of acute Achilles tendon ruptures shows a very different comparison. One should understand that this method is tailored towards acute injuries and patient selection becomes more important for better outcomes. Glazebrook and Rubinger developed the Glazebrook/Rubinger Achilles protocol for nonoperative treatment (GAPNOT) which has specific inclusion and exclusion criteria.⁶ I suggest reviewing this protocol and keeping it under consideration if you have access to physiotherapists familiar with this method. Some of the highlights include early diagnosis and treatment within 48 hours of injury, supervision by a qualified physical therapist is essential for successful management and weakness due to overstretching of the Achilles tendon can be mitigated with communication between the therapist and physician by modifying the protocol as needed.

Lastly, Soroceanu and colleagues performed a meta-analysis of randomized trials of Achilles tendon ruptures treated surgically versus nonsurgically.⁷ Ten studies met inclusion criteria, which yielded equal re-rupture rates in both groups. Surgical patients returned to work 19.16 days sooner (p = 0.0014), but there was no statistically significant difference between the two groups in regards to calf circumference, strength, or functional outcomes.⁷

Where does that leave us? Let us go back to the tenet that we should treat patients how they want to be treated. Each patient will have specific needs and expectations. Having nonsurgical and surgical options will ultimately lead to tailoring the treatment to what best suits their needs. We should all attempt to maximize our expertise and resources to treat patients effectively with the goal to optimize patient outcomes. Not all Achilles tendon injuries require the same treatment. I think I know how I would want to be treated in certain injury scenarios. I just hope the treating surgeon is respectful of my wishes.

Dr. Husain is the Residency Director of the McLaren Oakland Hospital Podiatric Surgery and Medicine Residency Program in Pontiac, MI. He is a Fellow of the American College of Foot and Ankle Surgeons and a Fellow of the American Society of Podiatric Surgeons. Dr. Husain is also the President-Elect of the Michigan Podiatric Medical Association and Chairman of the Michigan Podiatric Residency Consortium.

Dr. Qureshi is a third-year podiatric resident at McLaren Oakland Hospital in Pontiac, MI.

References

1. Leppilahti J, Puranen J, Orava S. Incidence of achilles tendon rupture. Acta Orthop Scand. 1996;67(3):277-279.

2. Kannus P, Józsa L. Histopathological changes preceding spontaneous rupture of a tendon. a controlled study of 891 patients. J Bone Joint Surg Am. 1991 73(10):1507-1525.

3. Plecko M, Passl R. Ruptures of the achilles tendon: causes and treatment. J Finn Orthop Traumatol. 1991;14:201-204.

4. Khaliq Y, Zhanel GG. Fluoroquinolone-associated tendinopathy: a critical review of the literature. Clin Infect Dis. 2003;36(11):1404-1410.

5. Kvist M, Jozsa L, Järvinen M. Vascular changes in the ruptured Achilles tendon and paratenon. Int Orthop. 1992;16(4):377-382.

6. Glazebrook M, Rubinger D. Functional rehabilitation for nonsurgical treatment of acute achilles tendon ruptures. Foot Ankle Clin. 2019;24(3):387-398.

7. Soroceanu A, Sidhwa F, Aarabi S, Kaufman A, Glazebrook M. Surgical versus nonsurgical treatment of acute achilles tendon rupture: a meta-analysis of randomized trials. J Bone Joint Surg Am. 2012;94(23):2136-2143.

8. Deng S, Sun Z, Zhang C, Chen G, Li J. Surgical treatment versus conservative management for acute achilles tendon rupture: a systematic review and meta-analysis of randomized controlled trials. J Foot Ankle Surg. 2017;56(6):1236-1243.

9. Wilkins R, Bisson LJ, Operative versus nonoperative management of acute achilles tendon ruptures: a quantitative systematic review of randomized controlled trials. Am J Sports Med. 2012;40(9):2154-2160.

10. Westin O, Nilsson Helander K, Grävare Silbernagel K, Möller M, Kälebo P, Karlsson J. Acute ultrasonography investigation to predict reruptures and outcomes in patients with an Achilles tendon rupture. Orthop J Sports Med. 2016;4:10.

11. Jiang N, Wang B, Chen A, and Dong F. Operative versus nonoperative treatment for acute Achilles tendon rupture: a meta-analysis based on current evidence. Int Orthop. 2012;36(4):765-773.

12. Brumann M, Baumbach SF, Mutschler W, Polzer H. Accelerated rehabilitation following achilles tendon repair after acute rupture - development of an evidence-based treatment protocol. Injury. 2014;45(11):1782-1790.