Which Repair Technique Is Superior For Acute Achilles Tendon Ruptures In Athletes?

Could a minimally invasive approach to Achilles tendon repair improve outcomes in elite athletes? A recent study published online ahead of print in the Journal of Foot and Ankle Surgery compiled data on a total of 186 patients with 188 ruptured Achilles tendons over a more than 17 year period. A single surgeon performed 85 open repairs and 103 percutaneous repairs among the subjects. Basketball was the sport where the ruptures most commonly occurred (n=29).

The study authors concluded that, even in elite ballistic sport athletes, patients with acute presentation of an Achilles tendon rupture exhibited similar outcomes at one year with percutaneous repair, local anesthesia and absorbable sutures than those who had an open repair. The patients underwent measurement of the Roles and Maudsley (RM) score, calf atrophy, return to activity and ability to execute a single-leg heel raise. The cohort overall showed a 9.6 percent complication rate. Of note, patients with non-absorbable sutures, more frequent in open repairs, had more wound complications (P=.003). In general, those who had open repairs also experienced more wound complications (P=.001).

The authors also found that the cohort repaired percutaneously with absorbable suture had less complications overall (P=.0007). Patients in the study returned to activity at an average of 8.2 ± 2.9 months, with no differences between genders. Additionally, patients who were unable to perform a single-leg heel raise postop also exhibited decreased activity levels.

Amol Saxena, DPM, FACFAS, FAAPSM, lead author on this study, shares that although the focus was on athletes, the data could also apply to non-athletic populations.

“Patients need confidence that they can return to their desired activities after Achilles tendon rupture, especially those that are athletic,” he says. “If sedentary individuals incur ruptures, they could become more sedentary, so a safe technique is beneficial to them as well.”

Nicola Maffulli, MD, PhD, also an author on the article, developed the percutaneous technique used in the study. He shares that he began using this approach in 2003 and has performed more than 1000 cases in his personal series.

Both doctors cite the simplicity of this particular approach, along with its versatility and potential cost savings due to performance under local anesthesia, with no need for jigs or a tourniquet.

“This is the largest single-surgeon study to date, says Dr. Saxena, a Past President of the American Academy of Podiatric Sports Medicine. “This eliminates suture and postop protocol variation. Percutaneous repair with absorbable suture had the lowest wound complications in this study, yet many in the U.S. still use non-absorbable suture for Achilles tendon repairs.”

Dr. Saxena points out that males and females showed no difference in their return to activity and Roles and Maudsley scores.

“We found 65.5 percent were able to return to their desired activities which is similar to other studies on professional athletes,” he adds.

With more studies soon to be published on the topic, Dr. Maffulli, Professor of Trauma and Orthopaedics at the University of Salerno in Italy, and Honorary Professor of Sports and Exercise Medicine at Queen Mary University in London, England, stresses that outcomes do not depend on surgical technique alone.

“Without good rehabilitation, even the perfect surgery will fail,” he says. “Your best friend will be your physiotherapist.”

Commemorating 10 Years Of A Partnership In Limb Salvage

By Jennifer Spector, DPM, FACFAS, Managing Editor

A series of special communications recently published online in the Journal of the American Podiatric Medical Association celebrate the 10-year anniversary of the alliance between the American Podiatric Medical Association (APMA) and the Society for Vascular Surgery (SVS). These communications highlight the interdisciplinary work of these two organizations, leading to collaborative manuscripts and meetings, along with formulation of common classification systems and treatment pathways, to ultimately work towards enhanced patient outcomes. These articles share that there are now hundreds of interdisciplinary limb salvage teams, at least in part due to these efforts.

Lee Rogers, DPM, DABPM, a co-author on several of the communications, shares that ten years ago podiatry and vascular surgery were two specialties with a common goal, the prevention of amputations.

“The growing public need fueled a thought-change in the natural history of diabetes-related amputations through the understanding of the “stairway to an amputation,” and the different roles both specialties play,” he says.

In the past decade, Dr. Rogers feels that team-based care has become the best practice for amputation prevention.

“Not only have podiatry-vascular teams formed across the globe, but we’ve researched the impact of these teams and found that it is a key driver of successful outcomes in limb salvage,” he explains.

Looking to the future, he says the 2019 Global Vascular Guidelines, endorsed by the APMA, shift the paradigm in the podiatric-vascular care of the patient with chronic limb threatening ischemia (CLTI).

“This alliance will continue to promote the best practice models of care at APMA and SVS continuing medical education meetings and continue to publish on the collaboration,” says Dr. Rogers, the Treasurer of the American Board of Podiatric Medicine.

Dr. Rogers directs readers to a similar paper among these special communications, “The Significance of the Global Vascular Guidelines for Podiatrists” as a resource for answers to key questions in the diagnosis and management of the threatened limb.¹

What Can We Learn About Burnout Among Podiatric Medical Students?

By Jennifer Spector, DPM, FACFAS, Managing Editor

A recent cross-sectional study in-press in the Journal of Foot and Ankle Surgery aimed to evaluate perceptions of burnout and related metrics in podiatric medical students. Each student at eight podiatric medical schools received a 50-question anonymous survey including the Maslach Burnout Inventory-Human Services Survey and the Hospital Anxiety and Depression Scale. A total of 479 responses were eligible for inclusion (22.2 percent response rate), with data regarding demographics, free time, study time, loan debt, family support and other factors.

Respondents reported moderate or high self-perceived rates of burnout at a rate of 65.1 percent, including high levels of emotional exhaustion and anxiety and low levels of personal achievement. The study identified the most at-risk population to be third-year students between the ages of 26 and 35 with borderline or abnormal levels of reported anxiety. The authors conclude that these findings should encourage institutions to promote and develop preventive programs addressing student burnout.

Elizabeth Ansert, DPM, and Calvin Rushing, DPM, AACFAS, both authors of the paper, relate that unfortunately, the overall findings in their study did not surprise them.

“There is so much to learn and do as a student, it can become overwhelming,” adds Dr. Ansert.

Dr. Rushing shares that data such as that from this study could stimulate discussion and remove stigma regarding burnout among podiatric medical students.

“APMA has gone to great efforts to make resources regarding burnout available, and students should be aware of and feel encouraged to utilize those resources if necessary,” he says.

Building awareness, helping faculty recognize burnout symptoms, higher-risk students and creation of research-based programs to prevent and combat burnout are among other potential results that could stem from this study, says Dr. Ansert, a second-year podiatric medicine and surgery resident in the Northeast U.S.

“The medical community in general is leading the burnout discussion, although the podiatric profession has admittedly lagged behind,” says Dr. Rushing, a fellowship-trained podiatrist in practice in Sunnyvale, Tx. “The profession as a whole has some catching up to do, and more research, akin to what exists from our MD/DO colleagues across a number of subspecialties, is warranted.”

Dr. Ansert stresses that in her personal research, communication and support is crucial to prevent and reverse burnout.

“If more members of the podiatric community become willing to communicate with students about this, or on this topic in general, I think that would go a long way,” she says.

1. Rogers LC, Conte MS, Armstrong DG, Lavery LA, Mills JL, Neville RF. The Significance of the Global Vascular Guidelines for Podiatrists: Answers to Key Questions in the Diagnosis and Management of the Threatened Limb. J Am Podiatr Med Assoc. 2021. Available at: https://doi. org/10.7547/20-217 . Published March 17, 2021. Accessed April 9, 2021.