D Miller, S Waterston*, J Reaper*, V Barrass*, N Maffulli
Department of Trauma and Orthopaedic Surgery, Keele University School of Medicine, Hartshill, Thornburrow Drive, Stoke-on-Trent; *Department of Orthopaedic Surgery, University of Aberdeen Medical School, Polwarth Building, Foresterhill, Aberdeen
Correspondence to: N. Maffulli, Department of Trauma and Orthopaedic Surgery, Keele University School of Medicine, Hartshill, Thornburrow Drive, Stoke-on-Trent, Staffordshire ST4 7QB. Email: n.maffulli@keele.ac.uk
SMJ 2005 50(4): 160-165
Abstract
Background and Aims: To ascertain the differences in patients’ perceived outcomes between conservative, percutaneous or open repair of Achilles tendon ruptures. Methods: We studied 111 patients who had been managed for a unilateral closed Achilles tendon rupture. We excluded patients with open Achilles tendon lesions, patients whose tear had occurred more than seven days from operation, patients with diabetes, inflammatory disease, systemic corticosteroids or fluoroquinolones. Patients were contacted by telephone and asked to answer a questionnaire. Results: There was no difference in effects on working life, patient satisfaction, sports performance, muscle strength, swelling and fear of re-rupture. Pain on weight bearing and cramps were significantly more frequent in the patients managed conservatively. Re-rupture and complication rates were comparable to published rates. Conclusion: Treatment should be individualised according to the demands and health of the patient.
Key words: Achilles tendon, rupture, repair
Introduction
Although the Achilles tendon is the most commonly ruptured tendon in the human body,1 there is still no consensus on the best form of management. Over the last two decades, open repair has been the treatment of choice for young people and athletes.2-9 Advocates of this technique report lower re-rupture rates, superior strength, power and endurance.2-9 However, there can be relatively high complication rates with this method, with around 12.3% for minor wound and 2.3% for major wound complications.2 Percutaneous repair minimises skin healing problems associated with open repair, possibly with higher re-rupture rates.10-13 More recent techniques have minimised the relatively high rates of sural nerve injury,14, 15 and offer outcome comparable to open repair.16
Conservative management has higher re-rupture rates than both percutaneous and open repair techniques.17-21 This method is often employed for elderly patients and those who wish to avoid surgery.22 Nevertheless, in teaching centres conservative management can be extremely successful.23 Few studies have evaluated the results of conservative, open and percutaneous management of Achilles tendon rupture.24 In our setting, Achilles tendon ruptures are managed in either of the three modalities described above. We therefore decided to undertake a study reviewing the complications, recovery and outcome of patients treated for Achilles tendon rupture by percutaneous repair, open repair, and non-operative management over a seven year period. We hypothesised no difference in long term results between the three modes of management of Achilles tendon ruptures.
Patients and methods
Ethics
All the procedures described in this study were performed after local Ethical Committee approval had been granted by the Grampian University Hospital Trust. Written informed consent was given by all patients undergoing surgery. The local Ethics Committee deemed it unnecessary to seek written informed consent for patients who took part in the telephone interviews.
Patients
A list of the 172 patients who had sustained a unilateral rupture of the Achilles tendon during the period 1990 to 1996 was obtained from a previously compiled database.25 We excluded from this investigation patients with open Achilles tendon lesions, patients who had originally been managed for a re-rupture, patients whose tear had occurred more than seven days from presentation to our Department, patients with diabetes, inflammatory disease, systemic corticosteroids or fluoroquinolones.
Original home addresses were available for all 172 patients. Eight patients were deceased. In the winter 2000-2001, a letter was sent to these 164 patients to invite them to take part in a telephone survey. We obtained 145 positive responses. We then tried to contact telephonically each patient to administer the questionnaire. We sent a questionnaire to complete, and asked to return it in a stamped addressed envelope to 32 patients who either did not have a telephone or whose telephone numbers were incorrect. Questionnaires were also sent to two patients whom we unsuccessfully tried to contact on seven separate occasions for the telephone interview.
In all patients, a diagnosis of midsubstance subcutaneous tear of the Achilles tendon was made clinically.26 Patients underwent one or the other mode of management (see below) according to the day of the week when they presented to the care of our institution, or by expressing a strong wish for one over the other management modes.
Age, sex, side, operative details (if an operation had been performed) and mode of injury were recorded. For the group of patients as a whole, and for each of the three different management protocols employed, we assessed the outcome of treatment using the four following categories:
(i) Excellent - no pain and no limitation of activity
(ii) Good - little pain and little limitation of activity
(iii) Satisfactory - intermittent pain and intermittent limitation of activity
(iv) Poor - constant pain and constant limitation of activity
We assessed patients’ satisfaction, and we studied the effects of the injury on their working life. The amount of time lost from work and any current effect on work performance were studied. We assessed whether patients’ participation in sport had been affected by their Achilles tendon rupture by investigating the amount of time lost from sport, the proportion of patients who had reduced or stopped their participation in sport, and the effects of the injury on performance in the sports in which they still took part. The overall re-rupture and complication rates were also calculated.
Conservative management
At presentation, a below knee plaster of Paris cast in maximal equinus of the ankle was applied. Patients were asked not to bear weight on the operated leg, and were encouraged to keep the leg elevated as much as possible for two weeks. The cast was removed at that stage, when the ankle was plastered in a more plantigrade position, and the patients were reviewed after a further two weeks. At this stage, the ankle was put in a synthetic cast as close as plantigrade as possible, patients were encouraged to increase their weight bearing as much as possible, with a view to discarding their crutches as soon as possible. Patients were given an appointment six weeks from the original cast application, when the cast was removed.
Surgery
All patients who underwent surgery were operated within 48 hours of presentation to our Department. The procedures were performed under general, regional or local anaesthesia, according to the patients’ general condition and preferences. Patients were positioned prone with both feet dangling from the end of the operating table. The foot, ankle and lower leg were prepared with standard antiseptic solutions taking care to clean the interdigital spaces. The toes where then covered with a sterile glove.
Surgery: open technique
Patients were operated using a previously described open technique.27 All patients had a complete midsubstance tear of the Achilles tendon 2 to 6 cm proximal to its insertion on the calcaneus. An end-to-end repair was performed using a single modified Kessler suture, extending just proximal to the Achilles tendon insertion distally and just distal to the musculotendinous junction proximally. The suture material used was No 1 Vicryl (Polyglactin 910 braided absorbable suture, Johnson & Johnson, European Logistics Centre, 66 Rue de la Fusee, B-1130 Bruxelles, Belgium) or No 1 PDS (Ethicon W9234T).
The repair was tensioned to reproduce the physiological minimal equinus present in the opposite ankle. A running circumferential suture with 3-0 Vicryl reinforced the core suture. The repair was thicker than the original tendon, and the paratenon, even when viable, could not always be sutured over it. Continuous 4-0 Vicryl reabsorbable sutures were used for the subcutaneous fat, and the skin was closed with interrupted 4-0 Ethilon (Ethicon, Johnson & Johnson, European Logistics Centre, 66 Rue de la Fusee, B-1130 Bruxelles, Belgium) or with a subcuticular 4-0 Vicryl reabsorbable suture. The skin wound was dressed with gauze, and sterile plaster wool was applied.
A below knee plaster of Paris cast with the foot in gravity equinus was applied. When the cast had dried, patients were encouraged to mobilise with the use of crutches, under the direction of a physiotherapist. Patients were discharged within three days of the operation, after having been taught to use crutches by an orthopaedic physiotherapist.
Surgery: percutaneous technique
Patients were operated using a previously described percutaneous technique (14). 15 ml of 1% lignocaine with 1 in 200 000 epinephrine (Astra Pharmaceuticals, Westborough, MA, USA) were infiltrated along the medial and lateral borders of the Achilles tendon over a region of 8-10 cm, centred upon the palpable gap in the tendon. A stab incision was made at the lateral border of the tendon, 4 cm above the palpable gap. This was repeated to produce three stab incisions on each side of the tendon: 4 cm and 2 cm above the gap, and 2 cm below the gap. With a straight Mayo needle, a heavy suture (No 1 Vicryl (Polyglactin 910 braided absorbable suture, Johnson & Johnson, European Logistics Centre, 66 Rue de la Fusee, B-1130 Bruxelles, Belgium) or No 1 PDS (Ethicon W9234T) was passed through the proximo-lateral incision, through the tendon and out of the proximo-medial incision. The suture was then passed through the tendon from the proximo-medial to the mid-lateral incision. A haemostat was passed from the distal lateral incision to the mid-lateral, and used to pull the suture (without the Mayo needle) through. The suture was remounted and passed through the tendon from distal lateral to distal medial. The haemostat was used to pass the unmounted suture from the distal medial to the mid-medial incision. The mounted suture was then passed through the tendon from the mid-medial to the proximallateral incision (the starting point of the suture). With the ankle plantar flexed, the suture was tied firmly, and, once the ends were cut, the knot retracted into the wound.
Post-operative care
A below knee plaster of Paris cast without increasing the natural minimal equinus of the ankle was applied. Patients were asked not to bear weight on the operated leg, and were encouraged to keep the leg elevated as much as possible for the first two post-operative weeks. The cast was removed two weeks after the operation, when the skin sutures, if used, were removed. The ankle was plastered in a more plantigrade position, and the patients were reviewed four weeks after the operation, when the ankle was put in a synthetic cast as close as plantigrade as possible. At this stage, patients were encouraged to increase their weight bearing as much as possible, with a view to discarding their crutches as soon as possible. Patients were given an appointment six weeks from the operation, when the cast was removed.
Care after removal of the cast
Patients were provided with a 1.5 cm felt heel raise to place in their shoes, reducing it by 0.5 cm every second week. Patients mobilized the ankle under physiotherapy guidance. Cycling and swimming were started two weeks after removal of the cast. Patients were prompted to increase the frequency of their self-administered exercise program, and were told that they could return to their sport on the fifth postoperative month.
Follow up
After application of cast and discharge from hospital, all patients were given an appointment for review after two weeks (OPD1). At OPD2 (4 weeks after presentation), the plaster of Paris cast was removed, the wound again inspected, and a synthetic below knee cast was applied, with the ankle 15° short of neutral. At OPD3 (6 weeks after presentation), the cast was removed, and the patient referred to physiotherapy for active mobilisation. At OPD4 (12 weeks after presentation), patients were assessed as to whether they were able to undertake more vigorous physiotherapy. Further follow ups at 14 weeks (OPD5) and 18 weeks (OPD6) were arranged.
All patients were reviewed during the sixth post-operative month. They were then followed up at three month intervals. At nine or 12 months from the injury, once able to perform at least five toe raises unaided on the operated leg, and having returned to their work and/or their sport, they were discharged, or chose not to attend for further review as they perceived themselves as having reached an acceptable steady-state. On their outpatient appointment at nine or 12 months, patients were assessed using a semi-structured questionnaire on which the questionnaire used in the present study was based. Patients were prompted to contact their surgeon should any problems have arisen at any time after the injury.
Statistics
Data was entered in a commercially available database. Descriptive statistics were calculated. Significance was set at the 0.05 level etc. The chi-square, Fisher exact and Mann- Whitney Rank Sum tests were used to determine whether any statistically significant differences existed between the three different management protocols.
Results
Of the 172 patients (138 males (80%), and 34 females (20%) forming the original cohort of our study, 86 were managed by open repair, 54 by percutaneous method, and 32 conservatively. We obtained direct information from 111 (65%) of the 172 patients on the database at an average of 7.9 ± 4.4 years from their injury: A total of 84 were successfully contacted by telephone and 27 returned completed questionnaires. Of these 111 patients, 22 (20%) of their ruptures had been managed conservatively, 59 (53%) had open surgical repair, and 30 (27%) were repaired by percutaneous surgery. The average age, side of rupture, and sex were not significantly different in the study sample of 111 patients and the entire cohort of 172 patients.
For the whole cohort of 172 patients, the mean age at the time of injury was 45.2 years (SD 15.2 years, range 15 to 85 years). For the patients in whom the side of injury was recorded, rupture was left-sided in 62 patients (42%), and right sided in 86 patients (49%). The side of injury was not recorded in 24 cases. 119 patients (69%) were injured during sports, with football accounting for the largest number of injuries. The injury was classified as ‘home related’ in 36 patients (21%), and ‘work related’ in 17 patients (10%).
Surgically managed patients
A total of 140 of 172 patients were managed operatively (mean age 45, M:F ratio 3.3:1), with 86 patients undergoing open repair and 54 percutaneous repair. The overall complication rate for the open procedure was 11.6%, with a re-rupture rate of 1.2%.The overall complication rate for the percutaneous procedure was 24.1%, with a rerupture rate of 9.3%. Sural nerve entrapment or damage occurred in five (9.3%) cases.
Conservatively managed patients
Thirty-two patients were managed conservatively. Their mean age at the time of injury was 48.5 years, with a male to female ratio of 1.8:1. Follow up data was available on 22 of the 32 patients managed conservatively. The overall complication rate was 22.7%, two (9.1%) had sural nerve injury, and three (13.6%) had re-ruptures.
Patient satisfaction
Of the 111 patients who completed the questionnaire, 61 (55%) described the result of their management of a rupture Achilles tendon as excellent, 35 (32%) thought it was good, 13 (12%) said it was satisfactory, and only two (2%) individuals considered their outcome to be poor (Table II). No significant differences were found between the three different methods of management.
Effects on working life
At the time of injury 91 of the patients worked, nine were retired, and 11 were not in employment. The number of patients in the surgical group who were employed at the time of injury (28 and 48) was significantly greater than for the patients who were managed conservatively (p = 0.04) (Table III).
As a whole, patients took a mean of 10.3 weeks of sick leave (range 1 day to 9 months). All patients employed at the time of their rupture returned to work. Three individuals changed job following their rupture, but only two of these changes were as a direct result of the injury. Seventy-three patients (80%) reported that their tendon rupture no longer had any effect on their working lives, with 18 patients (20%) complaining of persistent problems at work due to their injury. These difficulties were all only minor, and included ankle stiffness, tiredness in the leg after standing for long periods of time, and slight pain. When the three management modes were compared for the number of patients who had returned to work, changed job, and still experienced problems at work as a result of their injury, no significant differences were found.
Effects on sports performance
Of the 111 patients who completed the questionnaire, 23 did not take part in sport, 52 participated in sport at a recreational level, and 36 were competitive athletes at the time of injury. Of the 36 who participated in competitive sport, 14 did so at club level, 19 at a regional level, one at a national level, and two took part in international competition. A significantly greater proportion of the individuals who were managed by percutaneous repair than those treated conservatively participated in sport before their injury.
Seventy-seven of the 88 individuals (88%) involved in sport before their injury returned to playing sport, and 11 (12%) no longer participated in sport (Table IV). No significant differences were observed for the number of individuals who had returned to sport since their rupture. Of the 77 patients who have returned to sport following their rupture, 34 (44%) reported that their injury had no lasting effects on their sporting ability. Eighteen individuals still experienced minor problems, such as ankle stiffness, occasional pain, and cramp, and three (4%) reported major problems, due to loss of strength in the triceps surae muscle complex. Sixteen (21%) patients have changed sport as a result of their injury, mainly because of fear of re-rupture if they were to continue to participate in the sport which caused their rupture.
The average amount of time lost from sport was 7.9 months (range from 2 to 24 months). No significant differences were observed between the three forms of management for persisting problems during sport, or for time lost from sport.
Pain on weight bearing
Eighty-seven of the 111 patients (78%) who completed the survey experienced no pain on weight bearing. Fifteen individuals (14%) reported pain after weight bearing for long periods, and nine (8%) experienced pain after weight bearing for short periods. When the three management protocols were compared, no significant differences were noted (Table V).
Pain at other times
A total of 91 patients (82%) reported no pain when not weight bearing, nine (8%) experienced pain during cold weather, and 11 (10%) felt pain at rest. The proportion of patients in the conservatively managed group who experienced pain while non-weight bearing was significantly higher than that for the group which underwent percutaneous repair (p=0.03). No patients suffered constant pain, either when weight bearing or at any other time.
Perceived reduction in muscle strength
Fifty-one patients (46%) reported a reduction in the strength of their triceps surae muscle group. Ninety-six patients (86%) were able to perform single leg tiptoe stands. Fifteen individuals (14%) were no longer able to stand on tiptoe, although one of these patients reported being unable to stand on tiptoe before the injury (Table VI). The proportions of patients who perceived reduced muscle strength and who were no longer able to stand on tiptoe were comparable for the three methods of management.
Swelling
A total of 18 patients (16%) experienced swelling in the area of the Achilles tendon (Table VI). The number of patients who suffered from swelling was not significantly different for each of the three groups of patients.
Cramps
Twenty-eight people (25%) suffered from cramps in the affected leg (Table VI). The proportion of individuals who suffered from cramp was significantly greater for the group of conservatively managed patients than for the patients who underwent surgical repair (p = 0.01).
Fear of re-rupture
Fifty-nine individuals (53%) were scared that their tendon might rupture again (Table VI). The level of fear of rerupture did not vary significantly between the three groups of patients.
Discussion
Most surgeons would opt for open Achilles tendon repair in athletic patients because of the lower re-rupture rates and improved strength and endurance.2 The three different modalities of management have varying reports of success and complication rates.3, 4, 6, 7, 8, 19, 28-30
Nistor conducted a randomised prospective trial in 105 patients, 45 of whom had operative management, and 60 non-operative. They reported higher re-rupture rates in the non-operative group but advocated conservative management because of the minimal functional differences and significantly higher complications in the operative group.20 Cetti et al prospectively randomised 111 patients, and reported higher re-rupture and complication rates in the conservative group and concluded that operative management was the method of choice.2 Similar results were reported by Moller et al,31 with a 23% re-rupture rate in conservatively managed paients. A recent Cochrane review concludes that open operative management of acute Achilles tendon ruptures significantly reduces the risk of re-rupture compared to non-operative treatment, but produces a significantly higher risk of other complications, including wound infection. The latter may be reduced by percutaneous repair.24
In our setting, the re-rupture rate of only 1.1% in patients undergoing an open repair compares well with previous studies, which report an average re-rupture rate of 2.9%.9 The complication rate of 24.1% for the percutaneous technique is higher than other studies, although the rerupture rate of 9.3% is similar to that reported in the literature.10-15Recent studies report much reduced rerupture rates in patients undergoing percutaneous repair.16, 32
Sural nerve problems are a recognised complication of percutaneous repair.10 Patients experience anaesthesia of the lateral aspect of the foot, and some report difficulty with shoes as a result of this. Damage to the sural nerve occurred in 9.3% of patients managed percutaneously, comparable with that reported by others.17 The percutaneous technique used in this study10 is also associated with a significantly weaker tendon repair and a higher re-rupture rate than that seen with open repair.33 More recent modifications of the percutaneous technique have produced a stronger repair, and lower risk of sural nerve injury.13, 34, 35
Management of Achilles tendon ruptures still remains controversial.24 There is no ‘standard procedure’ for management. Therefore, much relies upon personal preferences and opinions. To a certain extent, the choice of management involves weighing the pros and cons of different techniques. For example, the superior functional results produced by open surgical management should be weighed against the potentially serious postoperative complications. Non-surgical management may produce poorer functional results, but some of the problems of postoperative complications can be avoided. Indeed, more modern forms of conservative management have proven extremely successful.23 The lack of well controlled randomised trials of the three different management protocols makes it virtually impossible to say whether there is a definitive procedure for management of fresh ruptures of the Achilles tendon. Many management modalities have been described, 23, 36-40 but none has been proven to offer clear advantages to manage acute Achilles tendon ruptures.
Our patients reported little or no pain, or limitation of function, were satisfied of the treatment received, and felt that their everyday life had not been hampered. When examining these results, it is important to consider patients’ previous lifestyle. For example, a patient could have been retired when their tendon ruptured and, consequently, returning to their pre-injury level of activity would have been far easier than if one were a top ranking athlete.
Traditionally, surgical management has been associated with a relatively high rate of complications. In this study, relatively few patients developed complications, with no catastrophic wound infection and skin loss, and no deep vein thromboses. There was only one (1.2%) re-rupture in the open repair group compared to five (9.3%) in the percutaneous, and three (13.6%) in the conservative group.
Limitations of the study
We are aware that clinical outcome studies in this field are traditionally based on a measurement of objective clinical variables, such as muscle strength and range of motion. However, the goals of management for a given ailment vary for each patient, and the above measurement may not always reflect the outcomes that are important to the patients or indicate the effectiveness of the treatment methods. Therefore, patient-rated subjective and functional assessment should form an integral part of evaluation and/ or comparison of different treatments.
The management of patients with an Achilles tendon rupture was uniform within each group throughout the study, and the surgeons in charge of the patients were not involved in the final assessment of the patients. As it is common in studies dealing with working, geographically mobile subjects, we were not able to track down all the patients who originally entered the study. In this study, no formal randomisation was implemented. Given the long time lag between the original injury and the present investigation, it was inevitable that a sizeable proportion of patients would have been difficult to track down. Although age and sex distribution is not different between responders and nonresponders, and there does not seem to be significant differences in other variables under study as ascertained by medical notes review, we do not know whether our study population is biased. Unfortunately, we have no means to control for this. We acknowledge that the evidence for assessing post-treatment outcomes and for establishing causation is not as strong as that which would be produced by a randomised controlled trial. However, despite their limitations, such studies marry the realities of clinical practice with the rigours of scientific investigation, and can be valuable for the formulation of hypotheses for future prospective randomised trials. Nevertheless, the differences detected are present and actual, and, in the present climate of cost savings in medical care, should help increase the efficiency and effectiveness of a health system.
Conclusion
Some studies have shown no difference in functional outcome of conservative versus operative management for acute Achilles tendon ruptures. We investigated the three main methods of management for this condition, and found no statistically significant differences in effects on working life, patient satisfaction, sports performance, pain, muscle strength, swelling and fear of re-rupture in patients who, though three may have been engaged in sports, were not elite performers. Complication and re-rupture rates compared well with the current literature. The management of acute midsubstance subcutaneous tears of the Achilles tendon by open repair, percutaneous repair or conservative methods produces a high level of subjective satisfactory results in a non-selected population.
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