May 2011

BATTLES OF ACHILLES: The operative vs nonoperative treatment debate

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Early mobilization techniques have revolutionized both surgical and nonsurgical management of Achilles ruptures, but the resulting improved outcomes have ignited a heated discussion among practitioners as to which approach is best.

by Cary Groner

A minor skirmish erupted at the February meeting of the American Academy of Orthopaedic Surgeons when researchers from Canada presented a meta-analysis concluding that with early mobilization protocols, patients with ruptured Achilles tendons had similar rerupture rates whether they’d been treated surgically or nonsurgically.1

Part of the uproar related to the authors’ recommendation that when such functional rehabilitation was available, conservative treatment was preferred, although nonsurgical subjects took nearly three weeks longer to return to work.

“They were reporting surgical complication rates higher than I’ve ever seen in eighteen years of fixing Achilles tendons,” said Stuart Miller, MD, the session’s moderator, who practices in the department of orthopedic surgery at Union Memorial Hospital in Baltimore. Surgery was associated with an increased risk of 15.7% for overall complications in the meta-analysis.

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Miller didn’t know what may have led such numbers, but speculated that some studies may have included repairs done by general orthopedic surgeons rather than foot and ankle specialists.

“We were just reporting the complication rates contained in the peer-reviewed papers included in the meta-analysis,” said Mark Glazebrook, MD, PhD, the mentor and coauthor of Alexandra Soroceanu, MD, who presented the research. Glazebrook is an associate professor of orthopedic surgery, with foot and ankle fellowship training, at Queen Elizabeth Health Sciences Center in Halifax, Nova Scotia. “We did an exhaustive literature search, so it was rather irritating for people to suggest that the surgical complication rates were wrong. If they think so, then they should do their own study and show us what the real rate is.”

In any case, Miller subjected the research to an immediate straw poll.

“I asked the audience, ‘If you rupture your Achilles tendon today, how many of you are going to have it treated operatively?’” Miller said. “Ninety-five percent of the people in the room raised their hands.”

Glazebrook then conducted his own poll, asking audience members—most of whom were American surgeons—how many of them treated Achilles ruptures surgically. A similar number raised their hands, Glazebrook told LER.

“Then I asked, of those who’d raised their hands, how many had treated an Achilles rupture nonoperatively more than five or ten times, electively, where there wasn’t a contraindication to surgery,” he said. “About eighty percent of them dropped their hands. I told them it was interesting that so many thought operative treatment was the way to go when most had never seen or utilized nonoperative treatment. That’s when people got angry.”

Miller said that the study provoked such anxiety partly because it could be seized on by insurance companies as a reason to deny coverage for open fixation. He acknowledges that early mobilization is beneficial and leads to faster recovery; he just prefers to use it in his postsurgical patients.

Change in the Wind

As Glazebrook noted, other research supports the Canadian study’s conclusions. For example, a 2010 study of 97 patients in Sweden reported that when subjects were randomized to receive surgery or conservative care, and both groups were offered early mobilization, there was no significant difference in outcomes at 12 months.2 Nevertheless, despite the lack of statistical significance, the rerupture rate was 12% (n=6) in the nonsurgical group, vs. 4% (n=2) in those who were treated operatively—a difference the authors noted “might be considered clinically important by some.”

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A similar 2010 Canadian study of 144 patients concluded that by 24 months, outcomes were essentially identical between the groups, though there were more than twice as many complications in the surgical group as in the nonsurgical one (13 vs. 6, respectively).3

Kevin Willits, MD, the lead author of that paper, told LER that the results applied equally to high-level athletes, recreational athletes, and non-athletes.

“The key component of the protocol is the early functional rehabilitation, accelerated to the point that they’re actually moving their foot and ankle at two weeks,” he said. “We think that’s the biggest difference between nonsurgical approaches in the past and our multi-center study.”

Willits, an associate professor of orthopedic surgery at the University of Western Ontario in London, said that the Achilles tendon is unique in certain ways that make it amenable to nonsurgical repair.

“People think that when it ruptures, it’s like a meat cleaver hitting a rope, and it just goes flying apart with this huge gap in the middle,” he said. “But in reality the tear is like mop ends, and there are usually strands of tendon still in continuity, with no dramatic retraction.”

Blood enters the area of the tear, Willits explained, then the resulting clots form a kind of scaffolding on which the body begins to construct its repair.

“One major stimulus for this study is that this injury is often missed,” Willits said. “Someone was exercising, they felt a pop in the back of their heel, then they went to the ER and were told not to worry about it. You examine them some time later and there’s evidence of past rupture, but they’ve done pretty well. So you think, maybe if you can protect it for a while and guide it to the finish line, you won’t have to jump in and operate.”

Profiling

Research does demonstrate some important differences in outcomes between surgical and nonsurgical patient groups. For example, a 2010 Cochrane review reported that surgical repair was associated with a significantly lower rerupture risk (RR 0.41), but higher rates of complications including infections, adhesions, and skin numbness.4

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Some surgeons are reevaluating their approaches—concluding, for example, that patient profiling should play a role in decisions about who gets surgery and who doesn’t.

“I tend to offer surgery to younger, active patients, but that could include those under age sixty-five who want to return to their activities more quickly,” said David Richardson, MD, director of the orthopedic residency program at the University of Tennessee–Campbell Clinic in Memphis. “I was at that AAOS meeting and I thought some folks were a little hard on the speaker, but I think it’s partly because we worry that we haven’t really figured out what subgroups do as well with functional treatment as with surgery.”

According to Michael Loshigian, DPM, FACFAS, who practices in Manhattan and teaches at Mount Sinai Hospital, the first consideration is the general health and activity level of the patient.

“We tend to lean more toward a primary surgical repair in younger and more active patients, or in professional athletes who have time constraints in terms of getting back into rehab,” Loshigian said. “But for a more simple rupture, where the tendon ends have not retracted significantly, conservative care is becoming more the standard. A lot of the success of that depends on timing. If you have a patient that comes to you within the first ten days of injury, there’s a better chance nonoperative care will be effective.”

Loshigian noted that conservative therapy is also appropriate for degenerative injuries, as when chronic inflammation leads to a cycle of partial tearing and healing, with longitudinal splitting between the tendon fibers rather than a transverse rupture. In such cases, treatment may include physical therapy, orthotic management, splinting and off-loading, platelet-rich plasma injection, or radiofrequency treatment.

Jonathan Chang, MD, a clinical associate professor of orthopedics at the University of Southern California, acknowledged that there is wide variety in surgeons’ therapeutic criteria.

“If you talk to twenty surgeons you’ll get twenty different answers,” he said, adding that he profiles patients primarily based on age, activity level, and, to a lesser degree, profession.
“The younger the patient, the greater the likelihood that they’re going to be active and want a more robust repair, as opposed to expectant waiting,” he said. “But I’m not one of those dogmatic people that says everybody with an Achilles rupture should have surgery. In fact, in my practice less than fifty percent end up having it, but that’s because I see a clear dichotomy between sports-related injuries and degenerative injuries. The former usually have surgery while the latter usually don’t. I think this controversy erupted mainly because surgeons have had such good results from surgical repair. That’s why everybody had a hard time believing that the results from nonoperative treatment could be as good, but conventional wisdom is always correct until you rigorously test it.”

Lowell Weil, Sr., DPM, FACFAS, team podiatrist for the Chicago White Sox and the director and CEO of the Weil Foot-Ankle & Orthopedic Institute in Chicago, was also team podiatrist for the Chicago Bears for more than two decades. He recounted a case in which two players ruptured their Achilles tendons within a day of each other (not insignificantly, exactly six weeks after each one’s tendon had been treated with a cortisone injection by another physician for the team). After the ruptures, one player received surgery but the other did not, allowing Weil to observe an inadvertent, small-scale clinical trial.

“The one treated with casting had a lot of weakness later and had to have surgery to tighten up the tendon,” Weil said, though this was before early mobilization was used.

Weil also agreed that profiling plays an important role in such decisions.

“You have to consider the general physical status of the patient,” he said. “Are they obese? Are they poor surgical risks? Are they sedentary? In some cases, you’re better off going with a nonsurgical technique.”

The type of sport played may also factor in. An orthopedic surgeon Weil knows tore an Achilles and opted for nonsurgical treatment because he’s a cyclist, and puts less explosive stress on the tendon.

Weil, who is 70, would take a different route.

“If I ruptured my Achilles tomorrow, I’d have surgery, because I know I’d heal better,” he said.

Surgical techniques

Even when clinicians reach consensus about when surgery is indicated, they often disagree on how to go about it. The choices include open, percutaneous, and an in-between approach using a device called an Achillon (see photos).

The Achillon device, pictured at left prior to insertion, helps facilitate a stable tendon repair with multiple sutures, as seen at right. (Photos provided by Lowell S. Weil, Sr, DPM.)

Weil has used the Achillon for 15 years.

“This involves a small incision of two or three centimeters on the back of the Achilles, which allows us to repair the tendon very strongly with multiple sutures, then proceed with immobilization, reconstruction, and rehabilitation,” he said.

He estimates that 80% of surgeons still use an open incision approach, however.

“Surgeons in general are pretty conservative,” he said. “They don’t want to change what works.”

Jonathan Chang is one of those.

“For a tendon of this size, I don’t take any chances; I like to do an open procedure,” he said. “With the advent of the Krackow suture technique, the likelihood of rerupture is very small, because it’s a type of weave stitch that incorporates more of the tendon fibers. It’s so strong that it allows for earlier mobilization.”

Chang noted that good surgical procedures should also minimize complication risk.

“The skin in that area has a poor blood supply, as does the tendon,” he said. “But if you make the incision in the correct place, minimize contact with the skin as you’re operating, and proceed expeditiously, you shouldn’t have major skin-healing issues.”

Chang pointed out that in the Swedish study reporting relatively high complication rates, surgeons used a different suturing technique called a Kessler stitch, which he considers more appropriate for upper-extremity tendons such as those in the hand.

“I saw that and thought, ‘Well, of course you’re going to have more complications,’” Chang said. “If they knew how to do the Krackow technique, I would not expect to see that complication rate.”

Not everyone agrees, naturally.

“If you do a traditional, open approach, you have to deal with scar tissue and fibrosis from the surgical dissection, and there’s potential for interrupting the blood supply to the tendon itself, which can cause complications and delay healing,” said Michael Loshigian. “Minimally invasive techniques require only a few strategically placed, small incisions, and I think it’s advisable to use them if possible.”

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One study, in fact, compared the risk for complications other than rerupture in 83 patients randomized to receive either nonoperative care or minimally invasive surgery. Researchers reported a complication rate of 21% for surgical treatment, versus 36% for nonoperative therapy. The mean time to return to work was 59 days after surgery, versus 108 days after nonsurgical treatment.5

David Richardson favors using the Achillon device in most circumstances but dislikes the purely percutaneous approach.

“With percutaneous surgery, you’re just weaving needles through the Achilles, through the skin, without making an incision,” he said. “That makes me anxious about sural nerve injury. If I can’t use the Achillon distally enough, when the rupture is close to the calcaneal insertion, I’ll use a very small incision instead.”

The literature varies in its assessment of nerve-injury risk with purely percutaneous surgery. Several recent studies concluded that the approach is as safe as other procedures.6-8 Other researchers, however, have reported significant problems.9 The clinicians LER spoke with often expressed discomfort with the technique, largely due to concern about nerve injury.

Rehab protocols

Regardless of whether the patient is treated operatively or conservatively, research and clinical experience are leading to a consensus that early mobilization is vital for quick and effective rehabilitation.10 Protocols differ between practitioners, but mainly in the details.

“Tendon movement speeds up the healing process,” said Lowell Weil. “Even so, I think physical therapy for nonoperative cases lags three to four weeks behind operative PT.”

Weil and his partners start postsurgical patients in gravity equinus casts for about 10 days, then switch them to an articulated cam walker for roughly three weeks.

“As time goes on, we change the angle of the hinge so the foot moves from the equinus position to about sixty degrees, then seventy, then ninety, so we get to a normal position gradually. Then we move them into physical therapy.” Patients are allowed to run at 12 weeks.

For early mobilization, David Richardson puts his patients in a functional brace that allows some active range of motion.

“At three weeks I’ll begin to let them work on range-of-motion exercises and do touch-down for balance,” he said. “I don’t let them put any weight on it until six weeks, but then we begin formal physical therapy and let them begin to weight-bear in a walking boot with a two-inch heel lift. We remove an inch a week, then after three weeks they can begin heel rises.”

Margaret Kedia, PT, DPT, PhD, who works with Richardson at the Campbell Clinic, said that in their practice, physicians and physical therapists work closely together to ensure optimal rehabilitation protocols.

“Dr. Richardson likes his patients to do early mobilization on their own before they begin physical therapy, then we usually see them five or six weeks postop,” she said. “We typically get patients when they’re in a boot with three layers of heel, whether they’ve had surgery or not.”

Depending on the individual doctor’s preferences and assessments of tissue integrity, therapists will try to lower the patient’s heel one level every week or two.

“Weight bearing is very important, so in terms of rehab, we lower them down and start working on balance as soon as possible,” Kedia said.

Stuart Miller’s patients, by contrast, typically begin partial weight bearing and full ROM exercises a week after surgery.

“At six weeks, when they start their aggressive physical therapy, they’ve already got it moving,” he said. “We’re trying to avoid scarring the Achilles down to subcutaneous tissues, which will really hinder recovery and rehabilitation.”

At USC, Chang uses what he calls a hybrid protocol.

“I like to have plantar flexion casting for two weeks, neutral casting for two weeks, and then start motion,” he said. “For those who have a particularly robust repair, or for elite athletes, I frequently put them in a short-leg cast in a neutral position immediately, because I believe the repair is that strong.”

For nonsurgical rehabilitation, Kevin Willits starts patients in an ankle-foot orthosis with a rocker bottom and a 2 cm heel lift for two weeks, allowing only touch weight bearing.

“After two weeks, we allow them to bring their ankle to neutral in physiotherapy, and to start bearing weight with the cast and the lift,” he said. “At six weeks they have the heel lift removed, then at eight weeks we get them out of the boot, and they’re allowed to go into full dorsiflexion progressively.”

Taking stock of options

Mark Glazebrook emphasized that up-to-date research, not conventional wisdom, should provide the basis for patients’ informed consent.

“We want to make sure that patients are given an option for both operative and nonoperative treament, and that a surgeon presents those options based on available evidence, not on what they think,” he said. “Often what we think is wrong, and there are many examples of that in history.”

Glazebrook noted that in the first six years of his surgical practice, he treated 95% of Achilles ruptures operatively. In the past six months, he’s treated all 20 cases nonoperatively and has been equally happy with the outcomes.

For Michael Loshigian, decisions about surgical versus nonsurgical interventions are just the first step in a long process, in any case.

“The Achilles takes a tremendous amount of stress and strain,” he said. “I tell my patients to expect recovery to take six months to a year or more. It’s important for them to think long-term and have realistic expectations.”

Cary Groner is a freelance writer based in the San Francisco Bay Area.

References

1. Soroceanu A, Sidhwa F, Arabi S, et al. Surgical vs. Non-surgical treatment of acute Achilles ruptures: a meta-analysis of randomized trials. Presented at annual meeting of the American Academy of Orthopaedic Surgeons, San Diego, February 2011.

2. Nilsson-Helander K, Silbernagel KG, Thomee R, et al. Acute Achilles tendon rupture: a randomized, controlled study comparing surgical and nonsurgical treatments using validated outcome measures. Am J Sports Med 2010;38(11):2186-2193.

3. Willits K, Amendola A, Bryant D, et al. Operative vs. nonoperative treatment of acute Achilles tendon ruptures: a multi-center randomized trial using accelerated functional rehabilitation. J Bone Joint Surg Am 2010;92(17):2767-2775.

4. Khan RJ, Carey Smith RL. Surgical interventions for treating acute Achilles tendon ruptures. Cochrane Database Syst Rev 2010;8(9):CD003674.

5. Metz R, Verleisdonk EJ, van der Heijden GJ, et al. Acute Achilles tendon rupture: minimally invasive surgery versus nonoperative treatment with immediate full weightbearing: a randomized, controlled trial. Am J Sports Med 2008;36(9):1688-1694.

6. Doral MN, Bozkurt M, Turhan E, et al. Percutaneous suturing of the ruptured Achilles tendon with endoscopic control. Arch Orthop Trauma Surg 2009;129(8):1093-1101.

7. Tenenbaum S, Dreiangel N, Segal A, et al. The percutaneous surgical approach for repairing acute Achilles tendon rupture: a comprehensive outcome assessment. J Am Podiatr Med Assoc 2010;100(4):270-275.

8. Henriquez H, Munoz R, Caruco G, Bastias C. Is percutaneous repair better than open repair in acute Achilles tendon rupture? Clin Orthop Relat Res 2011; March 2 [Epub ahead of print].

9. Maes R, Copin G, Averous C. Is percutaneous repair of the Achilles tendon is safe technique? A study of 124 cases. Acta Orthop Belg 2006;72(2):179-183.

10. Twaddle BC, Poon P. Early motion for Achilles tendon ruptures: is surgery important? A randomized, prospective study. Am J Sports Med 2007;35(12):2033-2038.

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6 Responses to BATTLES OF ACHILLES: The operative vs nonoperative treatment debate

  1. I have treated ruptured achilles tendons only closed and have obtained excellent results in all of the patients(12). None were operated upon.

  2. Trevor Franklin says:

    I reruptured my achilles . I went from a less then one inch gap to a 2.5 inch gap. I want to avoid surgery. Can I? I am very athletic.

  3. Ben Sanders says:

    I guess because 80 percent of the surgeons raise their hand, surgery must be favored. One billion Chinese can’t be wrong!? I’ve rupture both Achilles, one 20 years ago and had surgery, the other recently Jan 2013 and opted for non-surgical. I am 50+. Don’t play basketball with your teenager. My major concern was “bridging the gap” but that was not even a consideration in classifying subjects in this study’s control groups, or any other study. There is virtually no critiques suggesting surgery is necessary to properly heal the ruptured tendon. Only minor challenges to the speed of healing, which seems to be much more affected by the aggressiveness of the rehab protocols. I engaged in aggressive rehab by necessity. Nose down -20 degrees fixed for 3 weeks in boot, but weight bearing within days. Progressive reduction in flexion for 6 – 8 weeks. ROM boot in to allow range of motion from -20 to whatever new setting. Without cast, I could very early “get at” my Achilles for light rehab motion, icing, and massaging. My gap disappeared by feel within two weeks. My calf muscle only exhibited minor atrophy. My surgically repaired Achilles was always twice as thick as my other one. Now, both tendons are comparable in thickness, which I find odd. I suffered terribly with my surgery on the other tendon. Still a nasty scar today. I think I had a little bit of adhesion. Doc too paranoid about re-rupture. Too much atrophy. Don’t know the insurance consequences of re-rupture on Doc?

  4. jdubski says:

    first off, thx for a great, well written article.
    i tore my achilles playing basketball one month ago and this is by far the best article i’ve come across online, covering all bases well for folks who are on the fence between surgery or non surgery.
    2nd, if you don’t trust your doctor, get a 2nd or even 3rd opinion. Or rather it wouldn’t hurt to do that anyways.
    Immediately after my achilles tear, i started on my research.
    After seeing the numbers that non surgery methods (ie with proper rehab) could be just as successful as surgery, I initially told my doctor to proceed with the non surgery route.
    He respected my decision, and my wish to be relatively mobile (ie, continue driving stickshift) and placed me in a walking boot (with no extra heel). I asked him if i needed to be in a cast (since everything i saw online suggested immediate immobilization), but he basically said no, we’ll see how it goes and made it a point to mention that if it didn’t go well that “reconstructive” surgery may still be needed.
    This concerned me, including the fact that this doctor only had one patient that he could recall that opted out of surgery, and he wasn’t even fully aware of the end result. ??!!
    Finally got a 2nd opinion (3 weeks after tear), the dr seemed more aware of the non surgery route, and he suggested that i should be in a pointed down cast for 6 weeks to allow proper healing, and that with my foot in its current position in walking boot, it could allow for creation of gap in my tendon which could cause rerupture (this made perfect sense to me).
    Long story short, since i’d be immobile anyways and it seemed like surgery would give me at least a month head start, i finally chose that option.
    God forbid this ever happen to me again, but if it does i may just take Ben’s route and do my own clinical trial 😉

  5. Tony Hatch says:

    Hello everyone. I ruptured my right achilles end of January while playing soccer on artificial turf. I went directly to ER and received a plaster cast/splint. Follow up with DR a few days later and decided to go non-surgical with a Plasma Rich Platlet (PRP) injection at two weeks with time served in a ROM boot/wedge (VacoCast). I started Physio at three weeks once per week which includes electro therapy on calf muscles to reduce atrophy, acupuncture with electro therapy, calf raises and protected weight bearing (using scale I’m at 25-50% of weight around 80-100lbs). Saw DR again yesterday for follow-up and Thompson test showed some improvement but still a ways to go. I removed a wedge from boot this morning changing angle of foot to more neutral approx. 15 degrees vs 20-25.

    Weeks and days leading up to the rupture I recall having a lot of soreness in the tendon back of heel. There was a previous ankle injury from when I was twelve which is likely a contributor so whether or not this injury could have been avoided is anyone’s guess but there was definitely a lack of range in motion on my right foot. As we age (38) the calves weaken and shorten, especially if activity is reduced.

    Great article by the way. I have heard that surgical complications can leave a person off his/her feet for as much as a year or more so hopefully non surgical methods with PRP prove to be the standard going forward. As far as returning to impact sport the jury is still out but if I do it will be a minimum of 8-12 months from time of rupture. I’d like to hear from people who returned to impact sport using non surgical recovery and whether or not they re-ruptured. hatch_tony@hotmail.com

  6. Joe Yamen says:

    I would agree, this is a well written article.

    I completely ruptured my left achilles tendon approximately 6 cm above the calcaneal insertion. I have received two opinions by surgeons:
    The first surgeon believes that I should have surgery due to the nature of rupture while the second believes that because the rupture is next to musculotendinous junction that it is difficult to stitch near muscle.

    While I am open to non-surgical treatment, I am thinking that because I have a complete rupture that maybe the surgical treatment might be the best option. I am thinking that the non-surgical approach is a more viable option for partial ruptures where the tendon fibers are still intact. In my case they are not.

    Does anyone have any feedback they can share as I am a little confused and need to make a decision in the next day or so.

    Regards
    Joe

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