evidence based management of acute achilles … mohon for achilles tendon ruptures: is surgery...
TRANSCRIPT
Evidence Based Management of
Acute Achilles Tendon Ruptures
KennethG.Swan,Jr.,MD
Disclosures
• None
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Clinical Question
• Whatistheop+maltreatmentforarecrea+onalathletewithanacuteAchillesrupture?
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• Achilles---LegendaryGreekheroofTrojanwarfame– DefeatedHector– CentralcharacterinHomer’sTheIliad– Saidtobeinvulnerableduetocoatofarmor– Asaninfanthismother,TheHs,triedtomakeAchillesimmortal,anddippedhimintheriverStyx,holdinghimbytheheel
– Achilleseventuallymortallywoundedbyanarrowtotheheel
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Achilles
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Achilles Tendon Rupture
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• RelaHvelycommoninjuryinadultmaleathletes• RecreaHonalathletes• 4thand5thdecade• Males~10:1
• Typicallyanon-contactinjury• “Pop”andpainandcannotRTP• Usuallycanwalkoffthecourt/field
Achilles Rupture
• Usually2-6cmfromheelcordinserHon
• Bloodflowwatershedarea?
• Pre-exisHngtendondegeneraHon?
• Injurycanalsooccurproximally(MTjxnormusclebelly)ordistally(atcalcaneus)…..
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Achilles Rupture: Diagnosis
• History– Age,mechanism,RTP?– Timeframe
• Exam– Swelling,Ecchymosis,Tendongap– Motorfxnmaybe+/-normal!– AbnormalThompsontest
• Imaging– Xraytor/oboneyavulsion,calcifictendoniHs– MRI:notnecessary,butgoodtoolifdiagnosisorlocaHonoftearindoubt
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Thompson Test
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Achilles Rupture: Treatment Options
• Non-operaHve– Castvs.Boot– NWBvsEarlyweightbearing– ImmobilizaHonvsEarlyfuncHonalrehab
• OperaHve– Openrepair
• PostoperaHvecasHngvs.boot• PostoperaHveNWBvs.Earlyweightbearing• PostoperaHveimmobilizaHonvsEarlyfuncHonalrehab
– Percutaneousrepair
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Achilles Rupture Treatment
• ConsideraHons:– Healingrate– Re-rupture– ReturntofuncHon• ADLs,Work• Sport
– Timeframe– ComplicaHons
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Achilles Rupture Treatment
• ConsideraHons:– Healingrate– Re-rupture– ReturntofuncHon• ADLs,Work• Sport
– Timeframe– ComplicaHons
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Operative vs Non-operative
• Historically:– Non-operaHvetreatment=short-legcast,NWBfor4-12weeks• Risk:Re-rupture(8%-21%)
– OperaHvetreatment=openrepair,thenshortlegcast,NWBfor4-8weeks• Re-rupturerate2%-5%• Risk:Infec:on/woundcomplica:ons(0%--5%)
CeCAJSM1993,MollerJBJS2001
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Operative vs Non-operative: EBM
• WhatdoestheevidencetellusregardingoperaHvevsnon-operaHvetreatmentofAchillestendonruptures?
• PUBMEDSEARCHOFRELEVANTLEVEL1-3STUDIES
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Levels of Evidence
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Operative vs Non-operative • Bhandari,ClinOrthopRelatRes,2001• Meta-analysis,6studies,~450paHents• OperaHve– ~6-8wkscast– Re-rupture3.1%– InfecHon4.7%
• NonOperaHve– ~8wkscast– Re-rupture13%
• “Surgerygenerallyrecommended”• ***WBstatusandROMnotwelldefined
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Op vs Non-Op
• Moller,JBJS(Br),2001• Level2ProspecHvestudy• Non-op
– 8wkscast,4wksNWB– 21%re-rupture(11pts,10justwhilewalking!)– ~50%abnormalfuncHonat2years
• Op– 2wksplaster,thenWBATinboot,func:onalrehab– 1.7%re-rupture– BeoerfuncHonaloutcome,earlierreturntowork
• RecommendaHons:SurgeryforAchillesRupturetopreventre-
rupture
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Early Motion after Achilles Injury
• Twaddle,AJSM,2007• RCT,Level1• OperaHveandNon-operaHvepaHentstreatedwithearlyROMaper2wksinequinusplaster
» AcHveDFtoneutral,Passive(gravity)PF
• NWBfor6wks,bothgroups• 42ptstotal,1yearf/u• Results:Nodifferenceinre-rupturerate(3total),nodifferenceinfuncHonalscores,noinfx
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Twaddle, 2007
• Conclusions:
• “…..ControlledearlymoHonisthemostimportantpartoftreatmentofrupturedAchillestendon”
• ControlledearlymoHonfoundtobesafe
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Early Motion after Tendon Repair
• Gelberman,etal.EffectsofearlyintermioentpassivemobilizaHononhealingcanineflexortendons.JHandSurg,1982
• Conclusions:EarlyprotectedpassivemobilizaHonaugmentsthephysiologicprocessesthatdeterminethestrengthandexcursionofrepairedflexortendons
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Collagen arrangement
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Early Range of Motion Makes Sense!
…..and, it appears to be safe
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Early Weight Bearing after Repair of Achilles Rupture
• SuchakJBJS(Am),2008• Level1study• EarlyWB(2weeks)vsDelayedWB(6weeks)apersurgicalrepair– Nodifferenceinre-ruptures(None!)– Nowoundissues**– BeoerearlyrecoveryinearlyWBgroup(socially,ADLs)– Only6monthf/u– EarlyWBaOerrepairissafe
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Op vs Non-Op, Early WB/PT
• Willits,JBJS(Am),2010• MulHcenterRCT,Level1,2yrf/u• 144paHents• OperaHvevsNonoperaHve– BothgroupsearlyWB(2weeks)andearlyROM
• Re-rupture~4.6%;nodifferenceb/tgroups– OperaHve(2),NonOp(3)
• Noclinicallyimportantdifferenceb/tgroups• Non-op,earlyWB,earlyROMagoodop:on
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Op vs Non-Op with early WB • Olsson,AJSM,2013[Sweden]• Level1,RCT,OpvsNon-Op,1yrf/u• Non-Op– WBAT,bootx8weeks
– ***NoROMexercisesforfirst8weeks!
– 10%re-rupturerate• Op– WBAT,bootx6weeks,gentleAROMto-15*starHngwk2– 0%re-rupturerate,12%superficialinfecHons(Abxonly)
• FuncHonalrecoveryNOT100%atayear(eithergroup),46%didnotRTPby12mos
• FxnltesHng(hopping,CMJ)worseat12mosinnon-opgroupvsop
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Non-Operative treatment of Achilles Ruptures with Early ROM and Early
WB appears to be as safe and effective as Operative treatment
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Non-operative Treatment...???
• Barfod,JBJS(Am),2014[Denmark]• RCT,Level1,1yrf/u• NonOp,WBAT(day#1)vsNWB(6weeks)• EarlyROM*bothgroupsat2weeks
– *PFtoneutral,5x/day
• Nodifferenceinoutcomes• 9%re-rupture(3/26WB,2/25NWB)!!!• 40-50%strengthdeficitc/llimbat1year• Only16%hadreturnedtopre-injurylevelofplayat1year• BeoerearlyQualityofLifeintheearlyWBgroup
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Non-Op, Early WB, Cast
• Young,JBJS(Am),2014[NewZealand]• Level1RCT,2yearf/u• 2groupsbothNon-Op,equinuscastfor8wks– NWBx8wks– EarlyWB(Immediate?)
• Re-rupture3%earlyWB,5%NWB,NODIFF• MaybeearlyrangeofmoHonDOESN’Tmaoer!• *Pa+entsexcluded(andoperatedupon)ifpresented>72hrsaSerinjury
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• EvidenceisnotclearifitistheearlyWBortheearlyROMthatgivesmoderndaynon-operaHvetreatmentgoodresults
• Regardless,Non-operaHvetreatment(withearlyROMand/orearlyWB)appearstobeaverygoodopHon
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Post-op Protocol
• Brumann,Injury,2014• SystemaHcreviewofRCT,post-opprotocols
• “ImmediateFWBleadstohigherptsa+sfac+on,earlyRTWandRTP”
• “Allfunc+onalparametersfavorFWB,butnottosta+s+calsignificance”
• “Noincreasedre-ruptureinearlyWBgroup”• “EarlyROM(at2weeks)superiorto[cast]immobiliza+onwithearlierRTPandRTWanddoesnotleadtohigherre-rupturerate”
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Anecdotal Evidence (Level )
• MedSchoolRoommate#1(OrthoMD,USC)– “AthletesneedrestoraHonofthetension,soIfixthemall!”
– InL.A.it’shardertotalkpeopleoutofsurgery….• MedSchoolRoommate#2(OrthoMD,Flagstaff)– RecreaHonaloutdoorathlete,torehisAchilles1yrago– Treateditnon-op,earlyWB,earlyROM– “nopain,noproblems,Ihavejogged,butnotyetsprintedorjumped…..”
– “recommendNonopforrecreaHonalathletes.Pros??”
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Summary Based on EBM Review
• Achillesrupturesmaybetreatednon-operaHvely• OperaHvetreatmentanopHon,butwoundinfecHonrisk
• Re-ruptureriskisdiminishedwithearlyROMandearlyWBinnon-operaHvepaHents
• OperaHveandNon-operaHvetreatmentshouldincludeearlyWBandearlyROM
• EarlyROMandearlyWBaresafe• Regardlessoftreatment,alarge#ofathletesneverreturntopriorlevelofplay….
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Clinical Question
• Whatistheop+maltreatmentforarecrea+onalathletewithanacuteAchillesrupture?
Non-operaHvetreatment*withearly protectedweightbearingandearlyROM
*IfoperaHvetreatmentchosen,earlyWBandearlyROMshouldbeuHlized
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THANK YOU!!!
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Achilles References 1) Ce{R,ChristensenS,EjstedR,etal.OperaHveversusnonoperaHvetreatmentofAchillestendonrupture.Am
JSportsMed1993;21(6):791-7992) MollerM,MovinT,GranhedH,etal.AcuteruptureofthetendoAchillis.JBoneJointSurg2001;83B(6):
843-8483) BhandariM,GuyaoGH,SiddiquiF,etal.TreatmentofacuteAchillestendonruptures:AsystemaHcoverview
andmetaanalysis.ClinOrthopRelRes2002;400:190-2004) TwaddleBC,PoonP.EarlymoHonforAchillestendonruptures:Issurgeryimportant?AmJSportsMed2007;
35(12):2033-20385) GelbermanRH,WooS,LothringerK,etal.EffectsofearlyintermioentpassivemobilizaHononhealingcanine
flexortendons.JHandSurg1982;7(2):170-1756) SuchakAA,BosHcGP,BeaupreLA,etal.Theinfluenceofearlyweight-bearingcomparedwithnon-weight
bearingapersurgicalrepairoftheAchillestendon.JBoneJointSurg2008;90A:1876-18837) WillitsK,AmendolaA,BryantD,etal.OperaHveversusnonoperaHvetreatmentofacuteAchillestendon
ruptures.JBoneJointSurg201092A:2767-27758) OlssonN,SilbernagelKG,ErikssonBI,etal.StablesurgicalrepairwithacceleratedrehabilitaHonversus
nonsurgicaltreatmentforacuteAchillestendonruptures.AmJSportsMed2013;41(12):2867-28769) BarfodKW,BenckeJ,LauridsenHB,etal.NonoperaHvedynamictreatmentofacuteAchillestendonrupture:
Theinfluenceofearlyweight-bearingonclinicaloutcome.JBoneJointSurg2014:96A:1497-150310) YoungSW,PatelA,ZhuM,etal.Weight-bearinginthenonoperaHvetreatmentofacuteAchillestendon
ruptures.JBoneJointSurg2014;96A:1073-107911) BrumannM,BaumbachSF,MutschlerW,etal.AcceleratedrehabilitaHonfollowingAchillestendonrepair
aperacuterupture—Developmentofanevidencebasedtreatmentprotocol.Injury,Int,JCareInjured2014;45:1782-1790
12) CostaML,MacMillanK,HallidayD,etal.Randomisedcontrolledtrialsofimmediateweight-bearingmobilisaHonforruptureofthetendoAchillis.JBoneJointSurg2006;88B:69-77
13) KeaHngJF,WillEM.OperaHveversusnon-operaHvetreatmentofacuteruptureoftendoAchilles.JBoneJointSurg2011;93B(8):1071-1078
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Early Weight Bearing after Achilles Rupture
• Costa,JBJS(Br),2006• Level1;1yrf/u• 2studies:
– Op(46pts),withimmediateWB,bootvsDelayedWB(8wks),cast– Non-Op(40pts),withimmediateWB,bootvsDelayedWB(12wks),cast
• NoEarlyROM• Opgroup:2re-rupturesinearlyWBgroup,1indelayedWB• Nonopgroup:1re-ruptureineachgroup• NodifferenceinstrengthorsHffnessb/tgroups
“EARLYWBISSAFEFORBOTHOPERATIVEANDNONOPERATIVETREATMENT”???
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Surgery and Functional Outcome?
• KeaHng,JBJS(Br),2011• PRCT,1yearf/u• PrimaryOutcome:FUNCTIONALOUTCOME• Op:6wks,NWB,cast
– 5.4%re-rupturerate– 8.1%infxrate
• Non-Op:10wks,NWB,cast– 10%re-rupturerate
• Plantarflexionpeaktorque~25%lessthanc/llimbinbothgroupsat1year;nodifferenceSMFAscoresOpvsNon-Op
• Conclusions:UnabletorecommendsurgeryforfuncHonalrecovery
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