I need some help with a decision I have to make about my ankle. I have an Achilles tendon rupture but I'm not sure if I need surgery or not. The physician's assistant at the surgeon's office talked circles around both options but I couldn't tell which way to go and she wasn't helping. What do you advise your patients?
For quite some time, there has been debate and controversy over the optimal way to approach management of the acute Achilles tendon rupture. Should it be treated surgically? Can the complications of surgery be avoided by going with a more conservative treatment plan? What is the best way to measure results? These uncertainties may be why your physician's assistant wasn't able to be more clear about which is the best treatment for you.
As you probably understand better now than before your injury, the Achilles tendon is a strong, fibrous band that connects the calf muscle to the heel. The calf is actually formed by two muscles, the underlying soleus and the thick outer gastrocnemius. Together, they form the gastroc-soleus muscle group. When they contract, they pull on the Achilles tendon, causing your foot to point down and helping you rise on your toes. This powerful muscle group helps when you sprint, jump, or climb.
The risk of rerupture is the primary concern when evaluating which treatment plan works the best. Other ways to assess outcomes can include strength, time to return to work or play, and complications. Besides re-rupture, postoperative problems (not likely with conservative care) can include infection, nerve damage, unacceptable cosmetic appearance (due to fibrosis and scarring), and blood clots.
A recent study was done to help surgeons in the evaluation process to know what works for which patients. The conclusions they came to from the information gathered might be of interest to you. Patient results were compared from conservative to operative care. The main goal was to see what the re-rupture rate was for operative care versus conservative (nonoperative) care. Secondary measures were as described above (strength, return to work/sports, and complications).
There were four major findings. First, open repair had a significantly lower rate of reruptures compared with conservative care. There were almost three times as many reruptures in the conservative care group compared with the surgical group.
Second, the number of deep infections was much higher in the group that had surgery. No one had infection in the conservative care group. Almost three per cent of the surgical group developed a deep infection that required additional medical care and delayed recovery.
Third, nerve damage and dissatisfaction with the scar were never problems in the nonoperative group but were reported in the surgical group. The number of blood clots was not significantly different between the two groups. And the time to return to work or play was shorter for the surgical group but the statistical values did not reach significance.
And fourth, strength could not be used as an outcome measure because the way strength was assessed was different from study to study. As a result, the strength measurements were not considered "standardized."
On the basis of this systematic review and meta-analysis, surgeons can expect to reduce a patient's risk of rerupture with surgical treatment of acute Achilles tendon ruptures. But the higher risk of postoperative complications must be taken into consideration. Athletes and active patients may prefer the stronger tendon that comes with surgical repair. Less active and older adults with fewer biomechanical demands on the damaged tendon may opt for the nonoperative approach.
Ryan Wilkins, MD, and Leslie J. Bisson, MD. Operative Versus Nonoperative Management of Acute Achilles Tendon Ruptures. In The American Journal of Sports Medicine. September 2012. Vol. 40. No. 9. Pp. 2154-2160.
*Disclaimer:* The information contained herein is compiled from a variety of sources. It may not be complete or timely. It does not cover all diseases, physical conditions, ailments or treatments. The information should NOT be used in place of visit with your healthcare provider, nor should you disregard the advice of your health care provider because of any information you read in this topic.