Written on
March 8, 2010 – 4:14 am | by normofthenorth
[Note: While this review, now 3 years old, is still a pretty good summary of the evidence on "op vs. non-op" and how it has changed since 2007, we've been having some more modern discussions, partly at my "The case for skipping ATR Surgery" page. And there are two new articles -- one a meta-study and one a journalistic summary of the "debate" -- that are especially worth reading: The meta-study is Soroceanu A, Sidhwa F, Arabi S, et al. Surgical vs. Non-surgical treatment of acute Achilles ruptures: a meta-analysis of randomized trials. Presented at annual meeting of the American Academy of Orthopaedic Surgeons, San Diego, February 2011.
And the journalistic summary is at http://lowerextremityreview.com/cover_story/battles-of-achilles-the-operative-vs-nonoperative-treatment-debate , entitled “BATTLES OF ACHILLES: The operative vs nonoperative treatment debate”. Following is my March 2010 summary of that debate. -Norm]
I just did a bit more online research of my “new fave” subject:
Is there any significant benefit to ATR surgery compared to the newer and quick-ish non-surgical protocols, like the one I’m following?
I keep hearing, even now, that serious athletes just HAVE to have the surgery if they’re serious about (a) avoiding re-rupture and (b) regaining their past (or achieving their best) strength and ROM. But the recent scientific studies I’ve looked at — one from NZ and one from Canada — both say (”prove”?) it ain’t so. But I keep hearing it, as if it is so.
Today, I looked harder to see what’s out there, and here’s what I found.
1) In the “old days” — including late 2001, when I tore my first ATR — there had been many studies that compared surgical vs. non-operative outcomes, and most of them concluded that at least some of the “athletic” outcomes (usually re-rupture rates) were better with surgery. That understanding was nicely summarized in a 2005 “meta-study” of all the earlier studies:
The Journal of Bone and Joint Surgery (American). 2005;87:2202-2210. Treatment of Acute Achilles Tendon Ruptures: A Meta-Analysis of Randomized, Controlled Trials, Riaz J.K. Khan et al: A 2005 meta-analysis of earlier studies, involving 800 patients and with “a variable level of methodological rigor and reporting of outcomes”. It found a 3-fold increase in re-rupture rates with non-operative care, and an 11-fold increase in other complications with surgery (both statistically significant). It also found that boots produced better outcomes than casts, and (slightly) that percutaneous surgery was better than open surgery.
2) Those studies may have randomized the two streams of patients, but they did NOT treat the two groups the same! Back then, the non-operative approach REALLY WAS “CONSERVATIVE”!! I.e., it was slower, and involved more immobilization and NWB than the post-op approach. And the evidence is very clear, especially now, that long immobilization and NWB (and no physio, etc.) are all BAD for outcomes.
3) The situation changed a LOT in 2007, with the publication of the study from New Zealand, which I think was the first to (a) use rapid rehab for everybody and (b) use the SAME rehab for everybody. So this study tested scientifically for the effects of the SURGERY, rather than mooshing the effect of the surgery into the same “soup” as the effect of the faster rehab protocol that usually went with surgery. That study is as follows:
Aukland, NZ, 2007: Bruce C. Twaddle, FRACS†,* and Peter Poon, FRACS, Am J Sports Med December 2007 vol. 35 no. 12 2033-2038, “Early Motion for Achilles Tendon Ruptures: Is Surgery Important?: A Randomized, Prospective Study”, http://ajs.sagepub.com/content/35/12/2033.abstract: (The number of patients randomized is not included in free Abstract.) “There were no significant differences between the 2 groups in plantar flexion, dorsiflexion, calf circumference, or the MFAI scores measured at 2, 8, 12, 26, or 52 weeks. One patient in each group was noncompliant and required surgical rerepair of the tendon. There were no differences in complications and a similar low number of reruptures in both groups.”
4) The next three studies, all from 2009, follow that same practice, thereby isolating the claimed (but maybe fictional) benefits of surgery from the ACTUAL benefits of rapid rehabilitation:
a) http://www.ncbi.nlm.nih.gov/pubmed/19825777?dopt=Abstract — Netherlands: Metz R, et al, Sept. 2009. 83 patients randomized into two streams. Excluding the patients (8 surgical and 9 non-surgical) with “major complications”, strength testing at 3 months and 6 months revealed only one statistically significant difference, in which the NON-surgical patients were stronger.
b) http://www.medscape.com/viewarticle/588904 — Canada: Kevin Willits, March 2009 paper at AAOS 2009: “Nonsurgical Rehab After Achilles Tendon Rupture Better Than Surgery”. 145 patients randomized. No statistically significant difference in strength or ROM or re-rupture rate between the two groups, in two years of follow-up. Very significant difference — 2.6 x — in the rate of “complications”, with more in the surgical group, of course. “This is a great study and a landmark paper, and it’s a model of how to perform a randomized controlled trial,” commented Paul Fortin, MD, director of foot and ankle surgery at the William Beaumont Hospital, in Royal Oak, Michigan, who moderated the session at which the paper was presented. “The data are very clean and it’s potentially practice-changing.”
c) Gothenburg, Sweden, May 2009: http://www.physorg.com/news161516132.html — Katarina Nilsson Helander randomized 100 patients. The study found “no difference in the re-rupture rate. A year after the injury, there was no difference in the patients’ own impression of symptoms and function”.
5) ALL of those studies from 2007 on, find that there’s NO benefit from the surgery, as long as both groups get identical and rapid rehab. And both groups do just fine, in all those studies. (In one of the studies, the NON-surgical patients are stronger on one test at the final check, and that’s the only difference that’s statistically significant!) And I’ve included all the recent studies I can find!
6) So, as far as I can see, there really is no excuse for some otherwise intelligent person to claim that the evidence shows that surgery produces better results, or better results for athletes, . . . than the non-surgical approach. Than the approach that’s still sometimes called “conservative”, though it shouldn’t be! The non-surgical approach seems to work just fine, just as well as surgery but without the pain and complications. A really CONSERVATIVE approach, however, does NOT work fine, with or without surgery!
As “regular readers” already know, I’m following the protocol from 4b, above. And so far, so good — though (at 12.5 weeks) I’m getting tired of waiting for a good stride push-off, and then for a 1-legged heel raise. But so far, I’m very impressed with my progress on the non-surgical protocol — and I’ve also got experience with the surgical side, from 8 years ago. My life is back to normal except for the volleyball and stuff, and way quicker than I recovered the first time, post-op. It’s hard to complain.
If anybody’s got anything to add, like good studies I’ve missed, please respond here.
Finally, in my research, I also found a new surgical article from Japan that is a real eye-opener:
Novel Approach to Repair of Acute Achilles Tendon Rupture: Early Recovery Without Postoperative Fixation or Orthosis(!). Am J Sports Med February 2010 vol. 38 no. 2 287-292, Tadahiko Yotsumoto et al. The abstract’s at http://ajs.sagepub.com/content/38/2/287.abstract .
They only had a small group, but they applied a surgical “technique of their own design” to the whole group. Here’s more:
“The patients started active and passive ankle mobilization from the next day, partial weightbearing walking from 1 week, full-load walking from 4 weeks, and double-legged heel raises from 6 weeks after surgery.
Results: The range of motion recovery equal to the intact side averaged 3.2 weeks. Double-legged heel raises and 20 continuous single-legged heel raise exercises were possible at an average of 6.3 weeks and 9.9 weeks, respectively. T2-weighted magnetic resonance signal intensity recovered to equal that of the intact portion of the same tendon at 12 weeks. The patients resumed sports activities or heavy labor at an average of 14.4 weeks. The Achilles tendon rupture score averaged 98.3 at 24 weeks. There were no complications.”
These are truly spectacular results, by anybody’s standards! (Doug53, eat your heart out!) I mean, 20 continuous single-legged heel raises at an average 9.9 weeks post-op! That’s Very Good.
If I were making the choice today, anywhere near Shimane University School of Medicine (wherever Shimane is!?!), I think I might just go for the surgery — THIS surgery!
The good news for all the future American ATR sufferers, is that it’s probably easier to teach an old ortho-surgeon “dog” THIS kind of “new trick”, than it is to get him — yes, him! — to admit that it’s better to skip the surgery altogether.
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