cbrauchli’s AchillesBlog

Rupture is a scary word

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Week 2 | Out of the Cast!

December 8th, 2020 · No Comments

Yesterday, exactly two weeks post-op, I went to the hospital. They removed the cast and stitches and one of the doctors checked it. She said it seemed to be healing nicely, no signs of infection of anything concerning. There is still quite a bit of bruising and swelling, which will just take some time. I am so happy to be out of the cast!

Stitches

After removing the stitches, they fitted me to an AirCast boot with a couple of heel raisers. The doctor said I could weight bear as tolerated, but that she expected it would take about three weeks for me to be able to do so without crutches. I took a few steps with crutches and could see how she was right. The AirCast boot allows my Achilles to stretch much more than I would have expected, even with the heel raisers, which makes it quite painful to put weight on it. After three weeks I am also supposed to remove one of the heel raisers.

When I got home, I immediately switched the boot to the VACOped I had from last time, and fixed the angle to 30º. It is way more comfortable than the AirCast and feels much safer. With the AirCast I feel that if I stumble or put too much weight on it, it will really hurt. Not the case with the VACOped. In addition, with the VACOped I am almost FWB already. There is some pain that prevents a smooth gait, but it’s much better than with the AirCast.

Overall, I don’t have a clear answer on a protocol yet. In three weeks I am supposed to remove one heel raiser, be FWB in the boot, and potentially start physical therapy then. It’s not as aggressive as other protocols I’ve seen on this site, and I would prefer to use the VACOped, so I am going to do some reading and explore other options. I would love to recover more quickly. Suggestions welcome!

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Week 0 | The Operation

November 26th, 2020 · 6 Comments

I got in touch with my doctor in an atypical manner: I sent him a LinkedIn message. It can be slow to get in touch with doctors themselves in the Netherlands, due to the healthcare system being referral-based. So your GP will refer you to someone (you can ask for a particular doctor or they can suggest one), then you will get an appointment with the doctor, and then you will meet said doctor to confirm the diagnosis and potentially schedule an operation. Just based on availability and turnaround time, this means it takes at least 24 hours to go from referral to talking to the doctor. If the doctor proposes a treatment plan that you don’t agree with or you’d like a second opinion, then it’s another business day or two before you can talk to someone else.

I was injured on Tuesday the 17th. I spoke to my GP on Wednesday. I went to the first orthopedic surgeon on Thursday and she proposed open surgery. I was looking for a minimally-invasive surgery, so I got back in touch with my doctor, who referred me to another surgeon on Friday, but that meant that, at the earliest, I’d be talking to this surgeon the following Monday. Surgery wouldn’t happen until Tuesday, if it all worked out perfectly. From what I had read, minimally-invasive procedures are only preferred in the first week or so after injury, after that open or conservative is preferable (I’m not sure why). Tuesday would be right on the cusp.

So, I got a little frantic and did even more research on doctors in the Netherlands. Ultimately, I found a doctor who had written a paper I found promising (mentioned in my last post) and sent him a LinkedIn message explaining my situation. To my surprise, and good luck, he responded! He was great. I was put on waitlist for surgery on Monday. If there weren’t too many accidents over the weekend, I would be operated on Monday!

I went in to the hospital (OLVG West) Sunday night for a COVID test, which fortunately was negative. I started fasting Sunday at midnight.

Monday (Nov 23) at 2pm I got a call to go to the hospital. I went in and, after my vitals were taken, was pretty much immediately whisked off to the operating room, where the team was waiting. I met the man I’d sent a LinkedIn message to, was given a spinal nerve block, some form of tranquilizer, and laid prone. I chatted with the anesthesiologist throughout the procedure. I could hear the surgery team at work and occasionally a pull, but nothing at all painful.

Afterwards, I said goodbye to the team, was taken back to the recovery ward, then to my room. The nerve block took quite a while wear off, about three hours. I didn’t feel much pain initially. My girlfriend came to pick me up, we picked up my medicines, and we went home. They are definitely lighter on the painkillers here than in other countries—I was only prescribed paracetamol for pain and some injections for anti-thrombosis.

At home, some more pain set in. It was pretty uncomfortable, 5 or 6 out of 10, and woke me up a couple of times, but not alarmingly high. Today, Thursday, three days after the operation, the pain seems slightly less. I’ve made an effort to keep my leg elevated as I lay on the couch all day, which seems to help.

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My Research

November 26th, 2020 · No Comments

After discussing with the orthopedic surgeon at Acibadem (the second hospital), who suggested open surgery, I decided to do some research.

The first part I wanted to decide on was whether to pursue conservative treatment or an operation. I still had the VACOped boot from my last rupture [1], so if I wanted conservative, I could almost do it all myself.

Conventional wisdom among doctors has been that, for active or young patients, operative treatment yields better outcomes—faster return to work, daily activities, and sports. Some folks on this blog, notably normofthenorth, have challenged that assumption. Since my last treatment had been conservative (though not as aggressive as some of the protocols out there), and yielded unsatisfactory results, I wanted to do more research this time.

First, some caveats. In Achilles’ tendon rupture (ATR) treatment, there are many possible variables and, to my knowledge, no study exists that compares and controls for all of them, so unfortunately it’s not possible to confidently assert that one treatment is best overall. And, unfortunately, it’s not always possible to compare studies’ results directly, since they often vary quite a few things between studies. One study’s conservative treatment may involve immediate full weight bearing (FWB) and another may wait 6 weeks. One study may be on a cohort between 18–70 years of age and another on 40–60 years of age. Sometimes I had to compare apples to oranges and approximate to what I thought the best treatment might be. And, finally, everything is limited by what is available locally. It’s no use to find the best operative technique according to some randomized controlled trial if no surgeon locally is comfortable doing it.

The first thing I wanted to do was understand more about the “ideal” conservative treatment and where I may have strayed last time. For context, my Achilles Tendon Rupture Score (ATRS), 30 months after rupture, is 81. I have significant weakness at full plantar flexion. I would have put my ATRS pre-rupture at 100. I wanted to know whether my 3-week stint in a cast at the start was too long. For this, I found the UKSTAR [2] study very helpful. This study compares plaster cast treatment vs immediate functional bracing, across 540 patients in UK hospitals. The study found no statistically different ATRS at 9 months post-rupture between immediate weight bearing with functional bracing (i.e., a walking boot) and a cast. The good news is, for those who pursue a conservative treatment, you should be able to weight bear immediately and not hinder your recovery. It does not improve long-term outcome (which was what I was curious about), but it certainly improves short-term quality of life.

So what happened? Well, in my research on conservative ATR treatments, the median ATRS at the last follow-up (usually 12–24 months post-rupture) was usually in the 80s (although with a high standard deviation). My ATRS is 81. So maybe I healed as expected for the conservative treatment. Maybe I need more PT. A silver lining in this second rupture is the opportunity to balance the strength in both legs now (I hope to close to full strength).

I started looking into doctors able to do minimally-invasive procedures. Some of the newer techniques, such as using an Achillon or an Arthrex PARS reduce some of the risks typically increased in a minimally-invasive technique over an open procedure (such as sural nerve damage). There are also some papers I found showing techniques using dresden devices (or other suture retrievers) that could avoid risk of sural nerve damage.

The summary of the pros/cons I found of minimally-invasive techniques as compared to open surgery:

  • Pro: Less scarring. Not just for aesthetic reasons, less scarring reduces the risk of having issue with footwear in the future or tendon adhesion to the skin.
  • Pro: Lower risk of infection. A smaller incision is by nature safer. Most minimally-invasive techniques do not even apply tourniquet since the cut is so small.
  • Pro: The hematoma is usually left intact in a minimally-invasive technique. In the first 72 hours after injury, a hematoma forms at the site of the rupture. Though typically considered benign and safe to remove in an open surgery, there is some research showing that it has an important effect in healing [3]. The hematoma has been shown to be important for the formation of new blood vessels (angiogenesis) and, as we all know, the Achilles’ tendon area receives little circulation, so all those new blood vessels are essential to healing.
  • Con: Increased of sural nerve damage. Not all minimally-invasive techniques run this increased risk, but many do.

Overall, it seemed like a minimally-invasive technique was best for what I wanted. I hope to find someone to do the operation with the Arthrex PARS, but I did not have any luck finding a doctor familiar with it in the Netherlands. After asking around, I found a surgeon in Amsterdam who preferred a minimally-invasive technique for ATRs. He had published a paper a few years back with his technique and results [4], which looked good, so I went forward with booking a surgery with him.

For those looking in the Netherlands, I found that trauma surgeons were more likely to be familiar with minimally-invasive procedures and use them for ATRs. Orthopedic surgeons here tends to prefer conservative treatment or open surgery.


[1] Funnily enough, I had been considering selling it for cheap the week prior to my rupture. I got it for free with my insurance, and I didn’t want to throw it away since it was in fine shape, so I thought I would sell it to someone who could benefit from it for just enough to cover shipping costs. Good thing I didn’t!

[2] Costa ML, Achten J, Wagland S, Marian IR, Maredza M, Schlüssel MM, Liew AS, Parsons NR, Dutton SJ, Kearney RS, Lamb SE, Ollivere B, Petrou S. Plaster cast versus functional bracing for Achilles tendon rupture: the UKSTAR RCT. Health Technol Assess. 2020 Feb;24(8):1-86. doi: 10.3310/hta24080. PMID: 32068531; PMCID: PMC7049909.

[3] Schell H, Duda GN, Peters A, Tsitsilonis S, Johnson KA, Schmidt-Bleek K. The haematoma and its role in bone healing. J Exp Orthop. 2017 Dec;4(1):5. doi: 10.1186/s40634-017-0079-3. Epub 2017 Feb 7. PMID: 28176273; PMCID: PMC5296258.

[4] Lansdaal JR, Goslings JC, Reichart M, Govaert GA, van Scherpenzeel KM, Haverlag R, Ponsen KJ. The results of 163 Achilles tendon ruptures treated by a minimally invasive surgical technique and functional aftertreatment. Injury. 2007 Jul;38(7):839-44. doi: 10.1016/j.injury.2006.12.010. Epub 2007 Feb 20. PMID: 17316642.

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The Accident (I Can’t Believe I Did It Again)

November 25th, 2020 · 2 Comments

I was playing squash last Tuesday, November 17th. I had warmed up a few minutes on the exercise bike, but I suspect not enough, and was playing the first match. I was taking it easy, not pushing to get every shot, like I usually do in the first match, but when I stepped back at some point, I heard and felt the characteristic snap. As I fell, I thought I had somehow overswung and hit my leg, but that made no sense. Before I hit the ground I knew what had happened. To say I was frustrated, to rupture my other Achilles’ tendon, after barely two years and an incomplete recovery from my first rupture, at a young age, as a non-smoker, being otherwise healthy and active, would be an understatement.

I called my girlfriend and she came and got me. We were dating, but in different cities, at the time of my last rupture, and she remembered how hard the last one had been for me. I’m happy to have her here for this one.

We went to the same hospital (Amsterdam Medical Center UMC) as for my last rupture, just to get an emergency room cast so I could sleep without moving the foot. With that, we went home and got some sleep.

The next day I went to another hospital, Acibadem, where they treated me for my first rupture after I was having pain during healing. They took an ultrasound and diagnosed a complete rupture, about 5cm above the calcanus and with a 2cm gap between the tendon ends. The orthopedist at this hospital suggested an open surgery, with an approximate 12cm incision. I pressed them on this, since in the little research I had done in one night, I felt that a minimally invasive one would be preferable. The doctor disagreed and, ultimately, made the good point that the best surgery was the one the surgeon was comfortable with. I couldn’t disagree with that, so I told them I would research some more and possibly get a second opinion before proceeding. We left it at that—I would call back if and when I wanted to schedule the operation there.

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Some Background (My First Rupture)

November 25th, 2020 · No Comments

I am a 31-year old male and this is my second Achilles’ tendon rupture (different sides). My previous rupture was when I was 29, on my right side. I’ve always been fairly athletic, so it surprises me to have had two ruptures already. I’ll never know the exact cause, but I suspect it’s a combination of bad luck and a period of around 6 months that I completely stopped exercising due to a badly bruised heel, then getting back into sport too quickly.

My first rupture happened playing ultimate frisbee. I was cutting, so I changed directions rapidly and that’s when it happened. I thought I stepped on an empty disposable plastic water bottle someone had left on the pitch. After a couple of steps, and seeing how flat and wide my foot looked in the shoe, I realized something had happened to my Achilles’. A teammate, who was a physiotherapist, did a Thompson test on the field and that confirmed what we suspected.

I went to the emergency room, where they put a cast on and told me to come back a couple of days later to see the orthopedic surgeon. When I did, he suggested conservative treatment and changed my cast for a lighter fiberglass one, which I kept on for three weeks. At this point I’d read enough on this blog to feel that conservative would be fine.

My right leg never got back to 100%, maybe 75%. I have significant weakness at full plantar flexion. I can’t say exactly what went wrong, but I suspect the conservative treatment we took was too conservative at the start and too fast later. After three weeks in a cast, my calf was much smaller and felt like jelly. I got a VACOped boot and wanted to get doing physical quickly. Every time I adjusted the degrees, it was quite painful.

My orthopedic surgeon wasn’t very attentive and just told me the pain was normal. I wound up getting frustrated and going to a different hospital to see a different orthopedist. They took an MRI, confirmed a small re-rupture and gave me some heel lifts for two weeks. It made all the difference. My Achilles healed, but my leg remains weak, two years later. I am not sure if it healed long or it can be helped with more physical therapy. Now that I have a second rupture, I guess it’s an opportunity to compare healing and also get some more time with a therapist on my previous rupture.

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