Posted by: rougemac | July 2, 2010

Surgery

It’s official, I have a complete rupture, and I was booked for Surgery on Wed July 7th.

Responses

Were you unconvinced by the latest randomized prospective studies, or was your surgeon, or what? I’ve done it both ways now, and I can certainly tell you which one is easier and more pleasant, even without surgical complications. I only got the surgery in late 2001 because “everybody knew” back then that strength, ROM, and re-rupture rates were all better after surgery. I still didn’t know that four recent studies had proved that all wrong (on all three counts!) until I actually met one of Toronto’s fanciest surgeons to schedule my second ATR surgery — and he told me he doesn’t do surgery that provides no benefit!

Do you know the rehab protocol your Doc is planning to use on you post-op? Boot, no cast? Hinged? Many of us have found that the simple act of getting a protocol on paper — a “road map” — is a huge boost for the psyche, for “informed consent”, for feeling like a partner in your own healing rather than a character in “The Prisoner”, waiting for some unseen authority figure to make an important decision about your future.

Good luck and good healing, whatever you do. (If you change your mind after getting the OR booked, you’re too late to be the first person here who’s done that, and been glad of it!)

I had a complete rupture on July 27, 2009 and surgery on August 3. After that everything went downhill in a hurry. On August 24, while on my way to Portland, OR moving our son’s things to college for his first year, my injured foot looked like an overripe eggplant, smelled like one too, with a gaping hole at the bottom of which you could see the internal sutures. Back to surgery the following day. I took antibiotics almost continuously from then until early January, had another surgery on October 3 to close the original incision and a fourth surgery on May 20 to remove the internal sutures because they had caused an abscess. Sure, the odds of all that happening are small, but when they happen to you, the odds immediately become 100%. And I didn’t even get MSRA which exists in every hospital in the world. I am just now, nearly a year later feeling like I can just about start running again. If I rupture either Achilles in the future, there is absolutely no way I would agree to surgery. If necessary I would just buy my own Vaco-cast and find a physical therapist who would follow the early weight bearing protocol. I could have been running long before this and in shape to enter a 5K race in 3 weeks. As it is I would be lucky to make a 8.5-9 minute pace and that isn’t good enough to be competitive in my age group.
Just say NO to surgery when it isn’t necessary.

Dr. said 2 weeks in a cast, another 2 weeks in a new cast…… I told him, I wanted to try different rehab program that put me in a MC Walker on week 3. Said he was open to the idea, and I told him I would bring him the UWO protocol I was going to follow. He was also aware of the recent Non-surgical rehab studies, and said he does surgery on anyone who has over a 60-70% tear, and since mine is 100% wrapped up in my calf, he suggested surgery as the best option. It put me at easy that he was fairly easy to talk to and uses both methods of repair. I am confident I made the right decision, and I am looking forward to moving ahead with the rehab.!!!!!!

Your getting somewhere, Rougemac, but don’t stop! Most of us got a lot less access to our surgeons after our healing began (with or without surgery) than before, so MILK it while you’ve GOT it!

Your surgeon may not be aware that the 4 recent studies (which all showed statistically identical results with and without surgery) were ALL done on COMPLETE AT rupture patients (at least to the accuracy of the preliminary diagnosis, which some may question). So the notion that a diagnosis of a complete ATR indicates surgery for better outcomes, flies straight in the face of the evidence from the studies!

There is a traditional “understanding” that partial ATRs are especially appropriate for non-surgical treatment, and total ATRs for surgery. The only study I’ve seen that comes close to testing the truth of that traditional “understanding” is one from 2007, done by a team that included the chief author of the UWO study (Kevin Willits). I didn’t include it on my bit.ly/achillesstudies page, because the results seemed weak and inconclusive and not very relevant, but it’s quite interesting in this discussion. It’s summarized in “Snider, M., Bryant, D., Fowler, P., Giffin, R., Spouge, A., Willits, K., THE ROLE OF ULTRASOUND IN PREDICTING OUTCOMES OF NON-OPERATIVELY TREATED ACHILLES TENDON RUPTURES, J Bone Joint Surg Br 2009 91-B: 244″ and is online at proceedings.jbjs.org.uk/cgi/content/abstract/91-B/SUPP_II/244 .

The study examined (retrospectively) the early UltraSound analysis of ATR patients that got the (UWO) non-surgical protocol, based largely on a version of that traditional understanding. More specifically, they asked this interesting question: “Is there a relationship between ultrasound-measured ATR gap size and functional outcomes in non-operatively treated achilles tendon ruptures, or not?”

All the patients had complete ruptures, but the measured gap size varied significantly. Since it seems totally “magical” and illogical that a non-surgical protocol can heal an ATR with a big gap (to everybody, including you and your Doc!) and create a “new” healed AT with the right length and good strength, it stands to reason that patients with big gaps should do worse with non-surgical rehab than patients with small gaps [or partial tears, following the same logic].

Logical, but according to the study, SIMPLY NOT TRUE!! Here’s the exact conclusion:

“Gap size was not significantly related to functional outcomes. Non-operative treatment produced very good results at one year follow-up with low complication rates. These results suggest that ultrasound estimation of gap size and location may be of limited clinical value in the management of achilles tendon ruptures.”

BTW, as I understand it, this is NOT a “fifth” randomized trial that shows that non-operative treatment works as well or better than surgery, because I’m pretty sure it’s just a re-analysis of the subgroup of patients in the UWO study (25 of 145) that had detailed UltraSound records that showed their gap sizes. (Double-counting? We don’t need no steenkin’ double-counting! ;-) )

Also interesting, I think, is that the 25 patients had their gaps ultrasonically measured in plantarflexion AND in DORSIflexion!! I’m pretty sure I would have punched anybody who tried to put me into dorsiflexion right after I tore my AT!!

Finally, many patients/bloggers here have been told that their particular ATR LOCATION was the reason they either needed surgery, or should not have surgery (and most followed that advice, either way). Though this study is admittedly a small one , it apparently also found that gap location is NOT correlated with non-surgical outcomes, so those “rules of thumb” may also be more “logical” than true. (It’s still possible, though, that surgery works less well with one location than the others.)

Hi Norm: I need to read the study again, I guess. I’ve been telling people that a complete tear was a no brainer for surgery and that the higher the tear the more likely a non surgical route would be successful. So, you’re saying that the studies support non surgical treatment for virtually any case?

Good luck with your surgery and rehab. Hope it all goes well. It sounds like your Dr. is willing to consider a boot sooner and listen to your questions and thoughts on all the protocols out there. At least for me, EWB and boot asap was the best. That is important. Keep the faith,

Gunner, the 4 new studies (the ones I’m trying to make famous ;-) ) all dealt with complete ruptures, AFAIK, so that “a complete tear was a no brainer for surgery” is now just an old myth!

The traditional preference for non-surgical immobilization for high tears does NOT seem to be based on unusual success from non-surgical immobilization (at least based on that small random sub-sample of 25), and is probably based on unusual difficulties for surgery there. (If the surgeon didn’t want to cut and stitch your AT, he’d naturally put you in a cast, even without the new studies showing excellent results.)

The 4 new studies clearly support non-surgical treatment for virtually any case, but especially complete ATRs in any location, any gap size (because that’s what they dealt with). It MAY also be true that non-surgical treatment is a BIGGER no-brainer for partial tears, though I haven’t seen any proof, just logic. And (after one small study) the non-surgical treatment doesn’t seem to work any better for high tears than any other location, though surgery may work worse there.

I think the up-to-date evidence-based case for ATR surgery is pretty restricted now. In my judgment, surgery probably makes sense:
1) for “old” ruptures,
2) maybe (likely?) for externally sliced ATs where the paratenon (sheath) is also ruptured, and
3) probably for anybody who can go get the “super-strong and super-fast” surgery and rehab from those two Japanese surgeons I cite at bit.ly/achillesstudies!

In ALL other cases, the evidence shows identical results with much lower risks by following the bit.ly/UWOProtocol protocol without surgery! Again, virtually EVERY practicing surgeon learned the OPPOSITE in Med School, and there’s no way to “recall” a surgeon or a medical education the way you can recall a Toyota. And ATR treatment is always a sideline for a surgeon, “the tonsillectomy of the leg”, and hardly ever a life-or-death issue. So it’s not surprising that it’s like turning a super-tanker to try to change ATR practice.

Thanks Norm. I guess I have been party to parlaying some misleading advice, which I can now correct. Accepting that a complete tear can, seemingly “miraculously”, reconnect by natural healing without surgery is hard to digest, I must admit, so I have plenty of sympathy for the docs who stay with surgery in those cases.

Thanks again for all you’re doing to promote better healing and science.

Does anyone have any expereince with the i walk free crutch? It seems to be effectively enable one to resume work quickly.

Mac, did you go through with the surgery? If so, I hope it went well and you’re not in too much pain — AND that you can return to your computer soon and keep us posted!

Keep a copy of bit.ly/UWOProtocol handy to make sure your Doc doesn’t keep you immobilized or NWB or out of PT any longer than the patients (post-op and non-op) who did extremely well on that fast modern protocol.

Tony, I think there are a few people here who’ve tried that knee-walk gizmo, and also several wheeled knee walkers. (Try the search bar.) The latter gizmos are much easier to find, but they don’t do stairs! The UWO protocol has Full Weight Bearing “as tolerated” at 4 weeks, so you wouldn’t have very long to use a crutch-substitute unless you’re non-weight-bearing for longer than that — and why do it? (I actually lined up a cheap kneeling walker on Craigslist, but then I kept following the protocol and put the crutches (and cane) away before getting around to buying it!)

Gunner, I can personally relate to, and sympathize with, the surgeons who keep doing needless ATR operations, and also those who pressure their patients into slow and sub-optimal rehab protocols. None of us got 100% at school, and none of us is getting 100% on the job, either!

But the folks who “blew” the oil well in the Gulf, and the ones who build the cars we recall and fix. . . there are lots of nice folks we can sympathize with as individuals while working to fix their mistakes and maybe even send them the bills for them! It’s not personal, it’s professional. And if I have to choose between sympathy for the out-of-date surgeons and sympathy for their patients, I know IMMEDIATELY where my sympathies lie!

Mac had the surgery. I got an e-mail that I thought was notification of a new reply here, but I guess he just e-mailed me directly. I don’t think I’m violating Mac’s privacy by posting it here, while he’s busy moaning and groaning:

“Surgery went well. I am stuck to the couch with my perk’s close by. I would never have imagined the pain from this surgery. Looking forward to my mc walker. I will keep everyone posted once i get more mobile.”

Good luck and good healing, Mac!

Thanks Norm for posting my email. Surgery lasted about 1 hour, but I was in the hospital for 8 hours for pre-op and post op waiting for the anesthetic to wear off. Once the freezing was gone it felt like the surgeon was playing baseball with my foot. I would have never imagined the pain from this surgery. I recently had my appendix out and post surgery was nowhere close in terms of pain. 2 Days Post op and it is already feeling better. In fact I slept last night w/o pain meds. July 19th I go back to see the surgeon for my boot…..Can’t wait.

Thanks again for all the well wishes before my surgery, it is nice to talk to people who have gone through the same thing.

Mac

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