cbrauchli’s AchillesBlog

Rupture is a scary word

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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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