Achilles tendon ruptures – to operate or not to operate

Squash is one of my favorite sports, although unfortunately plagued by frequent achilles tendon ruptures as all racket sports. The image is CC by penguincakes.

A recent meta-analysis comparing treatments for achilles tendon ruptures caught my eye. This is probably one of the most commonly debated injuries among young orthopaedic surgeons; “what would you do if you’re achilles ruptured?”. After a few beers we can keep at it for hours… Maybe we can finally move to more interesting topics after Soroceanu et al’s excellent article.

The meta-analysis is well thought through/executed:

  • A wide screening of databases
  • A scanning of the reference lists of included articles
  • A search through proceedings of relevant meetings from 2005 to 2011 to identify unpublished reports
  • Foreign language articles were translated

Results

Their main conclusion was that if an accelerated functional rehabilitation protocol was used there was no difference in re-rupture rates while there was an almost 4 times greater risk of complications after surgery. The complication consisted mainly of:

  • Infections – both deep and superficial
  • Necrosis – both skin and tendon
  • Fistulas
  • Scar adhesion
  • Sural nerve damage
  • Decreased ankle motion
  • Overlengthening of the tendon
  • Deep venous thrombosis and pulmonary embolus

A few thoughts

I’m a little dissapointed that the article wasn’t more detailed. I know it’s nice to have short articles but a more detailed description of the study methodology should be available. Some thoughts that dwell in my mind:

  • What is the definition of function early range of motion, the only mentioning is in the introduction:

… functional bracing and modified postoperative regimens allow patients to perform daily active plantar flexion exercises as soon as ten days following injury.

  • It would be interesting to see a funnel plot with the studies. It is a very thorough literature search and it would be nice to see if there is any indication of residual publication bias. The authors mention this in the methodology but I guess it never made it to print.
  • The most interesting plot is in my opinion figure 3, but why didn’t they enhance it by adding headlines instead of 0/1 – a reader should not have to read the subtext to be sure which group is 1 and which is 0. It would also be nice to have some color indicating the subgroups.

You can find the article here:

The protocol for accelerated functional rehabilitation

The rehabilitation protocol for the non-operative accelerated functional rehabilitation according to Willis et al:

  • 0-2 weeks
    • Posterior slab/splint
  • 2-4 weeks
    • Aircast walking boot with 2-cm heel lift
    • Crutches
    • Active plantar flexion and dorsiflexion to neutral, inversion/eversion below neutral
    • Knee/hip exercises with no ankle involvement
    • Non-weight-bearing fitness/cardiovascular exercises
    • Hydrotherapy
  • 4-6 weeks
    • Weight-bearing as tolerated
  • 6-8 weeks
    • Remove heel lift
    • Dorsiflexion stretching, slowly
    • Graduated resistance exercises
    • Proprioceptive and gait retraining
  • > 12 weeks
    • Sport-specific retraining

It was surprisingly hard to deduce exactly what the protocol was for the surgical/non-surgical treatments, as they were mixed into one table column. I’m stuck with the question; Why this minimalistic approach, what are the costs for including a table that motivate a supplement only available on the web?

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