Evidence Based Management of Acute Achilles … moHon for Achilles tendon ruptures: Is surgery important? Am J Sports Med 2007; 35(12):2033-2038 5) Gelberman RH, Woo S, Lothringer

Evidence Based Management of

Acute Achilles Tendon Ruptures

KennethG.Swan,Jr.,MD

Disclosures

•  None

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Clinical Question

•  Whatistheop+maltreatmentforarecrea+onalathletewithanacuteAchillesrupture?

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•  Achilles---LegendaryGreekheroofTrojanwarfame– DefeatedHector– CentralcharacterinHomer’sTheIliad– Saidtobeinvulnerableduetocoatofarmor– Asaninfanthismother,TheHs,triedtomakeAchillesimmortal,anddippedhimintheriverStyx,holdinghimbytheheel

– Achilleseventuallymortallywoundedbyanarrowtotheheel

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Achilles

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Achilles Tendon Rupture

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•  RelaHvelycommoninjuryinadultmaleathletes•  RecreaHonalathletes•  4thand5thdecade•  Males~10:1

•  Typicallyanon-contactinjury•  “Pop”andpainandcannotRTP•  Usuallycanwalkoffthecourt/field

Achilles Rupture

•  Usually2-6cmfromheelcordinserHon

•  Bloodflowwatershedarea?

•  Pre-exisHngtendondegeneraHon?

•  Injurycanalsooccurproximally(MTjxnormusclebelly)ordistally(atcalcaneus)…..

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Achilles Rupture: Diagnosis

•  History– Age,mechanism,RTP?–  Timeframe

•  Exam–  Swelling,Ecchymosis,Tendongap– Motorfxnmaybe+/-normal!– AbnormalThompsontest

•  Imaging–  Xraytor/oboneyavulsion,calcifictendoniHs– MRI:notnecessary,butgoodtoolifdiagnosisorlocaHonoftearindoubt

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Thompson Test

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Achilles Rupture: Treatment Options

•  Non-operaHve–  Castvs.Boot– NWBvsEarlyweightbearing–  ImmobilizaHonvsEarlyfuncHonalrehab

•  OperaHve– Openrepair

•  PostoperaHvecasHngvs.boot•  PostoperaHveNWBvs.Earlyweightbearing•  PostoperaHveimmobilizaHonvsEarlyfuncHonalrehab

–  Percutaneousrepair

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Achilles Rupture Treatment

•  ConsideraHons:– Healingrate– Re-rupture– ReturntofuncHon•  ADLs,Work•  Sport

– Timeframe– ComplicaHons

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Achilles Rupture Treatment

•  ConsideraHons:– Healingrate– Re-rupture– ReturntofuncHon•  ADLs,Work•  Sport

– Timeframe– ComplicaHons

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Operative vs Non-operative

•  Historically:– Non-operaHvetreatment=short-legcast,NWBfor4-12weeks•  Risk:Re-rupture(8%-21%)

– OperaHvetreatment=openrepair,thenshortlegcast,NWBfor4-8weeks•  Re-rupturerate2%-5%•  Risk:Infec:on/woundcomplica:ons(0%--5%)

CeCAJSM1993,MollerJBJS2001

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Operative vs Non-operative: EBM

•  WhatdoestheevidencetellusregardingoperaHvevsnon-operaHvetreatmentofAchillestendonruptures?

•  PUBMEDSEARCHOFRELEVANTLEVEL1-3STUDIES

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Levels of Evidence

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Operative vs Non-operative •  Bhandari,ClinOrthopRelatRes,2001•  Meta-analysis,6studies,~450paHents•  OperaHve–  ~6-8wkscast–  Re-rupture3.1%–  InfecHon4.7%

•  NonOperaHve–  ~8wkscast–  Re-rupture13%

•  “Surgerygenerallyrecommended”•  ***WBstatusandROMnotwelldefined

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Op vs Non-Op

•  Moller,JBJS(Br),2001•  Level2ProspecHvestudy•  Non-op

–  8wkscast,4wksNWB–  21%re-rupture(11pts,10justwhilewalking!)–  ~50%abnormalfuncHonat2years

•  Op–  2wksplaster,thenWBATinboot,func:onalrehab–  1.7%re-rupture–  BeoerfuncHonaloutcome,earlierreturntowork

•  RecommendaHons:SurgeryforAchillesRupturetopreventre-

rupture

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Early Motion after Achilles Injury

•  Twaddle,AJSM,2007•  RCT,Level1•  OperaHveandNon-operaHvepaHentstreatedwithearlyROMaper2wksinequinusplaster

»  AcHveDFtoneutral,Passive(gravity)PF

•  NWBfor6wks,bothgroups•  42ptstotal,1yearf/u•  Results:Nodifferenceinre-rupturerate(3total),nodifferenceinfuncHonalscores,noinfx

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Twaddle, 2007

•  Conclusions:

•  “…..ControlledearlymoHonisthemostimportantpartoftreatmentofrupturedAchillestendon”

• ControlledearlymoHonfoundtobesafe

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Early Motion after Tendon Repair

•  Gelberman,etal.EffectsofearlyintermioentpassivemobilizaHononhealingcanineflexortendons.JHandSurg,1982

• Conclusions:EarlyprotectedpassivemobilizaHonaugmentsthephysiologicprocessesthatdeterminethestrengthandexcursionofrepairedflexortendons

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Collagen arrangement

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Early Range of Motion Makes Sense!

…..and, it appears to be safe

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Early Weight Bearing after Repair of Achilles Rupture

•  SuchakJBJS(Am),2008•  Level1study•  EarlyWB(2weeks)vsDelayedWB(6weeks)apersurgicalrepair– Nodifferenceinre-ruptures(None!)– Nowoundissues**–  BeoerearlyrecoveryinearlyWBgroup(socially,ADLs)– Only6monthf/u–  EarlyWBaOerrepairissafe

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Op vs Non-Op, Early WB/PT

•  Willits,JBJS(Am),2010•  MulHcenterRCT,Level1,2yrf/u•  144paHents•  OperaHvevsNonoperaHve–  BothgroupsearlyWB(2weeks)andearlyROM

•  Re-rupture~4.6%;nodifferenceb/tgroups– OperaHve(2),NonOp(3)

•  Noclinicallyimportantdifferenceb/tgroups•  Non-op,earlyWB,earlyROMagoodop:on

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Op vs Non-Op with early WB •  Olsson,AJSM,2013[Sweden]•  Level1,RCT,OpvsNon-Op,1yrf/u•  Non-Op– WBAT,bootx8weeks

–  ***NoROMexercisesforfirst8weeks!

–  10%re-rupturerate•  Op– WBAT,bootx6weeks,gentleAROMto-15*starHngwk2–  0%re-rupturerate,12%superficialinfecHons(Abxonly)

•  FuncHonalrecoveryNOT100%atayear(eithergroup),46%didnotRTPby12mos

•  FxnltesHng(hopping,CMJ)worseat12mosinnon-opgroupvsop

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Non-Operative treatment of Achilles Ruptures with Early ROM and Early

WB appears to be as safe and effective as Operative treatment

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Non-operative Treatment...???

•  Barfod,JBJS(Am),2014[Denmark]•  RCT,Level1,1yrf/u•  NonOp,WBAT(day#1)vsNWB(6weeks)•  EarlyROM*bothgroupsat2weeks

–  *PFtoneutral,5x/day

•  Nodifferenceinoutcomes•  9%re-rupture(3/26WB,2/25NWB)!!!•  40-50%strengthdeficitc/llimbat1year•  Only16%hadreturnedtopre-injurylevelofplayat1year•  BeoerearlyQualityofLifeintheearlyWBgroup

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Non-Op, Early WB, Cast

•  Young,JBJS(Am),2014[NewZealand]•  Level1RCT,2yearf/u•  2groupsbothNon-Op,equinuscastfor8wks– NWBx8wks–  EarlyWB(Immediate?)

•  Re-rupture3%earlyWB,5%NWB,NODIFF•  MaybeearlyrangeofmoHonDOESN’Tmaoer!•  *Pa+entsexcluded(andoperatedupon)ifpresented>72hrsaSerinjury

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•  EvidenceisnotclearifitistheearlyWBortheearlyROMthatgivesmoderndaynon-operaHvetreatmentgoodresults

•  Regardless,Non-operaHvetreatment(withearlyROMand/orearlyWB)appearstobeaverygoodopHon

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Post-op Protocol

•  Brumann,Injury,2014•  SystemaHcreviewofRCT,post-opprotocols

•  “ImmediateFWBleadstohigherptsa+sfac+on,earlyRTWandRTP”

•  “Allfunc+onalparametersfavorFWB,butnottosta+s+calsignificance”

•  “Noincreasedre-ruptureinearlyWBgroup”•  “EarlyROM(at2weeks)superiorto[cast]immobiliza+onwithearlierRTPandRTWanddoesnotleadtohigherre-rupturerate”

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Anecdotal Evidence (Level )

•  MedSchoolRoommate#1(OrthoMD,USC)–  “AthletesneedrestoraHonofthetension,soIfixthemall!”

–  InL.A.it’shardertotalkpeopleoutofsurgery….•  MedSchoolRoommate#2(OrthoMD,Flagstaff)–  RecreaHonaloutdoorathlete,torehisAchilles1yrago–  Treateditnon-op,earlyWB,earlyROM–  “nopain,noproblems,Ihavejogged,butnotyetsprintedorjumped…..”

–  “recommendNonopforrecreaHonalathletes.Pros??”

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Summary Based on EBM Review

•  Achillesrupturesmaybetreatednon-operaHvely•  OperaHvetreatmentanopHon,butwoundinfecHonrisk

•  Re-ruptureriskisdiminishedwithearlyROMandearlyWBinnon-operaHvepaHents

•  OperaHveandNon-operaHvetreatmentshouldincludeearlyWBandearlyROM

•  EarlyROMandearlyWBaresafe•  Regardlessoftreatment,alarge#ofathletesneverreturntopriorlevelofplay….

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Clinical Question

•  Whatistheop+maltreatmentforarecrea+onalathletewithanacuteAchillesrupture?

Non-operaHvetreatment*withearly protectedweightbearingandearlyROM

*IfoperaHvetreatmentchosen,earlyWBandearlyROMshouldbeuHlized

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THANK YOU!!!

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Achilles References 1)  Ce{R,ChristensenS,EjstedR,etal.OperaHveversusnonoperaHvetreatmentofAchillestendonrupture.Am

JSportsMed1993;21(6):791-7992)  MollerM,MovinT,GranhedH,etal.AcuteruptureofthetendoAchillis.JBoneJointSurg2001;83B(6):

843-8483)  BhandariM,GuyaoGH,SiddiquiF,etal.TreatmentofacuteAchillestendonruptures:AsystemaHcoverview

andmetaanalysis.ClinOrthopRelRes2002;400:190-2004)  TwaddleBC,PoonP.EarlymoHonforAchillestendonruptures:Issurgeryimportant?AmJSportsMed2007;

35(12):2033-20385)  GelbermanRH,WooS,LothringerK,etal.EffectsofearlyintermioentpassivemobilizaHononhealingcanine

flexortendons.JHandSurg1982;7(2):170-1756)  SuchakAA,BosHcGP,BeaupreLA,etal.Theinfluenceofearlyweight-bearingcomparedwithnon-weight

bearingapersurgicalrepairoftheAchillestendon.JBoneJointSurg2008;90A:1876-18837)  WillitsK,AmendolaA,BryantD,etal.OperaHveversusnonoperaHvetreatmentofacuteAchillestendon

ruptures.JBoneJointSurg201092A:2767-27758)  OlssonN,SilbernagelKG,ErikssonBI,etal.StablesurgicalrepairwithacceleratedrehabilitaHonversus

nonsurgicaltreatmentforacuteAchillestendonruptures.AmJSportsMed2013;41(12):2867-28769)  BarfodKW,BenckeJ,LauridsenHB,etal.NonoperaHvedynamictreatmentofacuteAchillestendonrupture:

Theinfluenceofearlyweight-bearingonclinicaloutcome.JBoneJointSurg2014:96A:1497-150310)  YoungSW,PatelA,ZhuM,etal.Weight-bearinginthenonoperaHvetreatmentofacuteAchillestendon

ruptures.JBoneJointSurg2014;96A:1073-107911)  BrumannM,BaumbachSF,MutschlerW,etal.AcceleratedrehabilitaHonfollowingAchillestendonrepair

aperacuterupture—Developmentofanevidencebasedtreatmentprotocol.Injury,Int,JCareInjured2014;45:1782-1790

12)  CostaML,MacMillanK,HallidayD,etal.Randomisedcontrolledtrialsofimmediateweight-bearingmobilisaHonforruptureofthetendoAchillis.JBoneJointSurg2006;88B:69-77

13)  KeaHngJF,WillEM.OperaHveversusnon-operaHvetreatmentofacuteruptureoftendoAchilles.JBoneJointSurg2011;93B(8):1071-1078

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Early Weight Bearing after Achilles Rupture

•  Costa,JBJS(Br),2006•  Level1;1yrf/u•  2studies:

–  Op(46pts),withimmediateWB,bootvsDelayedWB(8wks),cast–  Non-Op(40pts),withimmediateWB,bootvsDelayedWB(12wks),cast

•  NoEarlyROM•  Opgroup:2re-rupturesinearlyWBgroup,1indelayedWB•  Nonopgroup:1re-ruptureineachgroup•  NodifferenceinstrengthorsHffnessb/tgroups

“EARLYWBISSAFEFORBOTHOPERATIVEANDNONOPERATIVETREATMENT”???

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Surgery and Functional Outcome?

•  KeaHng,JBJS(Br),2011•  PRCT,1yearf/u•  PrimaryOutcome:FUNCTIONALOUTCOME•  Op:6wks,NWB,cast

–  5.4%re-rupturerate–  8.1%infxrate

•  Non-Op:10wks,NWB,cast–  10%re-rupturerate

•  Plantarflexionpeaktorque~25%lessthanc/llimbinbothgroupsat1year;nodifferenceSMFAscoresOpvsNon-Op

•  Conclusions:UnabletorecommendsurgeryforfuncHonalrecovery

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