Monday, 20 August 2012

Achilles tendon ruptures: let the patient decide


As we age, our collagen loses its elasticity and our tendons weaken. A ruptured Achilles tendon (TA) is often the result. This is a common injury; patients are usually aged 30 – 50 and it normally occurs with a sudden push-off during sport. Now, the initial reaction when anything is torn is to repair it, and while this holds true for inanimate objects, living things are different – 4 billion years of evolution has made some headway in that regard. Many people do not appreciate that as surgeons, when something is broken, cut or torn, all we do is put the ends roughly together and it is nature that does all the healing; we just take the credit. Placing the torn ends of a ruptured TA together is easy: you just flex the ankle. And it turns out that if you do this, and gradually bring the ankle back to normal position over a few weeks, it heals fine – without surgery, and without the complications associated with surgery.

For this topic, there are many randomised trials comparing non-operative treatment to surgical repair, and almost as many systematic reviews of those trials. The fact that these trials are still being done means that we don’t really know what treatment is best. Consequently, surgeons develop their own opinions and either treat TA ruptures surgically, or non-operatively. This means that the treatment choice depends on the preference of the surgeon, not the preference of the patient. It is easy to sell such an operation (“Your tendon is ruptured and we want to sew it back together”), so what happens in many institutions is that patients who present with a ruptured TA simply get scheduled for surgery.

The different treatment preferences between doctors (instead of between patients) can be seen in studies like this one, where they compared the results between two large hospitals in Sweden, because one hospital treated them surgically, and the other treated them non-operatively. They found about half the re-rupture rate in the surgical group (3% vs 6.6%) but a higher infection rate (1.5% vs 0%). This study was a little biased towards surgery, because the surgical hospital tended to operate on the younger ones and leave the older ones out. For better evidence, we should look at the randomised trials.

The studies
In a Cochrane review of randomised trials comparing all forms of non-operative treatment compared to surgical repair, surgery was associated with a lower re-rupture rate (about half), but a higher complication rate (about 5 times higher; things like infection, skin tethering, numbness). Tests of strength tended to favour surgery (though not always), but tests of overall function are usually the same. Two more recent reviews (here and here) found pretty much the same thing.

But those are overall reviews including all forms of non-operative treatment. The more recent studies of functional non-operative treatment (basically letting the patient use the leg and walk on it, but in a special boot) are getting the best results we have seen from non-operative treatment. Recently, there have been studies like this one and this one, which still show a slightly lower re-rupture rate with surgery (about 1 – 2%), but a much higher complication rate. The functional recovery is similar with either treatment. Other studies, like this one, show no difference in the re-rupture rate between the two groups.

The bottom line
Non-operative treatment of Achilles tendon ruptures results in similar functional outcomes compared to surgery, and avoids the surgical complications of wound infection, scar adhesion and numbness. The price you pay for non-operative treatment is a higher re-rupture rate (between 1 and 3% higher). That’s the information you need to make a decision with your surgeon – don’t let them make the decision for you.

14 comments:

  1. Does this treatment work with biceps tendon ruptures? Fascinating, Assuming a total separation doesn't the tendon withdraw beyond reach when the Gastrocnemius and soleus contract? With outcomes so similar as these studies indicate I would seriously consider the less invasive treatment.

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    1. Thanks Rumi,
      Probably not for biceps tendon, as it retracts so far. TA ruptures are like two mop ends, and are easier to get together.
      If you can't get the ends together, the next question is: do you need to? For biceps tears in the shoulder, no; for the elbow, probably.
      The answer is always more complicated than "It is broken, we must fix it", which is as far as many of us go.

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  2. All that we are is the consequence of what we have estimation. Wait… Has anyone exhorted dissertation to you. Keep the articles progressing !
    scar-treatment-research.com

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    1. Thanks Ravi, I would like to see the placebo trials supporting your treatments.

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  3. I was recently reading some of these trails and work for surgeons who use both forms of treatment (the majority for surgery in most patients) and a few who use the functional rehab protocols.

    The JBJS study (2010) shows pretty impressive results for the non-op group, and interestingly uses the same accelerated rehabiliation program with the operative groups (as opposed to keeping the patient doing very litte for 6 or 8 weeks post surgery). However there were some comments regarding that article stating that it was underpowered to show a significant result even by the papers own power calcuations, and moreso if the significantly better performance than expected of the function rehab group was taken into account.

    My question is then: how do I interpret this trial and others like it when it comes to recommending treatments/ disussing the pro's and cons for my patients ?

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    1. Thanks mmv,
      You need to make your decision based on the totality of the evidence. Whether or not non-operative treatment is statistically better than surgery (sample size, power etc) should not be important. It is unlikely to be worse, based on that study and many like it, and therefore why subject patients to the risks of surgery for no gain?
      I think the results of all these studies is surprisingly consistent: non-operative treatment has similar functional results, a slightly higher re-rupture rate, but less wound complications. I give my patients the rough figures around this and they usually opt for non-operative treatment. You don't have to be that precise.

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    2. Thanks. That makes sense. I guess in interpreting papers we're always taught to look at significance, sample size etc. Granted if a large RCT shows a significant result it probably carries more weight, but I take your point that a large number of studies showing a similar outcome between two treatments suggests that there probably isn't a great deal of difference in terms of outcomes.

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  5. Thanks for the information. I opted for the non-surgical approach. I have been in a cast for three weeks ... headed for six weeks in a cast.

    Do you have any recommendations or websites you can point me to to get an idea of proper rehab that needs to take place. I want to be an informed consumer.

    BTW, I'm 57 and the injury occurred on the tennis court.

    Thank you.

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    1. Thanks Ken,
      The problem is that we don't know what "proper" rehab is. I base mine on the studies that have been published, so I guess the best thing would be to look up the articles referred to above, and to discuss with your treating doctor and physical therapist.

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  6. Can someone point to the pink elephant in the room? A 1-3% increased risk of rerupture is very close to insignificant. I'd guess it's within the error of measurement. What, do people just think scars are cool or something? I don't get it.

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    1. Thanks Jason,
      I think that people simply underestimate the harms from surgery - scars and numbness etc. Even the language that patients use: "I just want it fixed, properly" is a common quote. People see surgery as something that fixes things, properly, and without it, we are just mucking around trying to make the best of it.

      While I type this, a patient at my hospital is having an above-knee amputation for a complication from elective surgery. Sure these things are rare, but not nearly as rare as people think. Any wonder why surgeons often choose non-operative treatments?

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  7. Hm, I always thought that the operation is a must when it comes to achilles tendon rupture, after reading this article I`m all for non-surgical treatment.

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  8. Please see my forum (and post on there!) if you are getting the non-surgical treatment:

    achillesbusted.com/forums

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