Does The Evidence Support Traditional Concepts Of Achilles Tendon Rupture Etiology And Repair?

 

The approach to the evaluation and management of acute Achilles tendon rupture has experienced a constant evolution over the past five decades. Both surgical and non-surgical treatments have had extensive study, and a wealth of new evidence is available that has changed the most basic tenets of management of this common injury.

Despite the availability of very good studies that clarify and challenge our traditional thoughts, many traditions and misconceptions persist among foot and ankle surgeons. We will explore several aspects of acute Achilles tendon rupture including: whether repair is needed for good outcomes, current concepts of tendon hemodynamics and ischemia, and which steps in the repair algorithm are necessary.
To start the discussion, we will first explore the concept of tendon debridement during repair. This commonly recommended step highlights how historic evidence can create a bias in our approach to a common medical problem and how this bias can persist for decades despite the emergence of new evidence. The surgical repair of acute Achilles tendon ruptures commonly includes debridement of damaged tendon fibrils or “mop ends” at the rupture site.

Although we have historically seen debridement as necessary in the repair algorithm, we question whether it is necessary or prudent to resect any portion of the ruptured tendon. Removal of even a small segment of the midportion of the Achilles tendon results in shortening of the muscle-tendon unit and subsequent iatrogenic equinus.

In order to critically assess the common practice of tendon debridement in Achilles tendon ruptures, we must first answer the following questions:

1. What evidence supports the surgical resection of any portion of the damaged tendon?
2. How do we determine which portion of the tendon is beyond the capability for natural biologic repair?  
3. Is ischemia the proximate cause of Achilles tendon rupture?
4. Has this notion of midsubstance ischemia of the Achilles led to the recommendation of debridement because we think this section of tendon is necrotic?   

Addressing Ischemia And Vascularity In Achilles Tendon Ruptures

Although the notion of ischemia as the main etiology of Achilles rupture is ubiquitous in the discussion of the condition, there is little to no experimental evidence to support this conclusion.

The original study by Lagergren and Lindholm in 1959 used a cadaver model and mapped the blood supply with standard anatomic latex injection technique.1 The authors ascribed the term “watershed” to the vascular anatomy of the tendon because there were vascular components that came from both proximal and distal portions of the tendon, similar to the geographic term of a river watershed. They concluded that this anatomic distribution and orientation of blood supply leads to ischemia in the midsubstance of the tendon. Carr and Norris duplicated this experiment with the same conclusion in 1989.2

It is interesting that this notion of avascularity has persisted for many decades based on mapping of the static arterial anatomy in cadavers alone and not hemodynamic flow studies in live patients. Recent literature questions the concept of avascularity as a significant or sole factor for Achilles tendon tears.3 With the use of quantitative laser Doppler flowmetry, Astrom in 2000 and Astrom and Westlin in 1994 found that the midsection and origin are the areas of the Achilles tendon that are the most vascularized uniformly along the tendon, and that only the distal insertion has noticeably lower blood flow.4,5

Using a sodium washout, Hastad and colleagues showed there is a decrease in blood flow in all zones as we age, but the blood flow is consistent along the longitudinal course of the tendon.6 Astrom confirmed the uniformity of blood flow.4 Further evidence highlights a uniform increase in tendon blood flow to the Achilles tendon throughout its length.7–10

We wonder if this notion of ischemia, which began with non-hemodynamic cadaver studies, coupled with the visual cues we see during exposure for acute repair, including hematoma and tendon fragmentation, has led us down the path of resection of a portion of the tendon without scientific cause. Let’s face it. The tendon at the rupture site looks bad when we directly visualize it. If we are biased by what we learned about “watershed ischemia,” debridement seems reasonable.

What The Literature Says About Non-Operative Achilles Care

A somewhat less direct approach to answer the question of whether the tendon is ischemic is to examine the results of non-surgical care for Achilles tendon ruptures. A growing number of recent studies indicate that the functional outcomes and re-rupture rates for non-surgical management using early functional rehabilitation are equivalent to surgical repair.

A 2017 Canadian study by Sheth and colleagues detailed that, although there has been a rise in acute Achilles tendon ruptures in recent years, there has been a significant decrease in the incidence of surgical repairs since 2009.11 The authors found that the rate of surgical repairs in Ontario, Canada dropped from 20.1 percent in 2003 to 9.2 percent in 2013.

This drop in surgical repairs in Canada could have contributed to recent literature that supports non-operative treatment. In a 2017 systematic review and meta-analysis, Deng and coworkers found no statistically significant difference in the incidence of deep vein thrombosis (DVT), functional scores or ankle range of motion (ROM) between the surgical and non-surgical groups.12 The authors also showed that the re-rupture rate for surgical patients of 3.7 percent was statistically lower than that of the non-surgical group (9.8 percent).

Twaddle and Poon previously explained the prevention of this increased rate of re-rupture in non-surgical patients in 2007.13 The authors observed surgical and non-operative patients who both partook in early range of motion, and found no significant difference in complications, re-rupture rates, dorsiflexion, plantarflexion, calf size or the Musculoskeletal Function Assessment index between the two groups. Lim and Gwynne-Jones also found no significant difference in Achilles tendon total rupture scores between operative and non-operative treatment groups that followed the same functional bracing protocol.14 Thus, Twaddle, Lim and and their respective colleagues concluded, as did Barfod and colleagues in 2014, that early active rehabilitation is more important for tendon healing than surgery.13–15

Comparing Achilles tendon repair patients in early weightbearing and six-week delayed weightbearing groups, Suchak and colleagues found the early weightbearing group had better RAND-36 and ROM outcomes at six weeks.16 At six months, there was no longer this difference between the two groups and patients had the same complication rate. Young and coworkers achieved this early active rehabilitation by allowing non-operative patients to use weightbearing casts, and these patients had outcomes equivalent to non-operative patients who were non-weightbearing.17

Hutchison and colleagues noted low re-rupture rates (1.1 percent) and satisfactory Achilles Tendon Total Rupture Score, Achilles Tendon Repair Score and functional outcomes when using the Swansea Morriston Achilles Rupture Treatment program (SMART), which includes early weightbearing.18 A Level I study by Willits and coworkers “supports accelerated functional rehabilitation and nonoperative treatment for acute Achilles tendon ruptures” due to the patients having similar clinical outcomes as operative patients while avoiding the complications associated with surgery.19 Bergkvist and colleagues agreed that non-operative treatment is the preferred protocol in most patients with acute Achilles tendon rupture due to a low re-rupture rate (6.6 percent) in non-surgical patients and the nonexistent chance of infection.20   

It would stand to reason that if the tendon can heal without surgery, it must not be significantly ischemic and is certainly not dead. In fact, the Achilles is just injured and experiences the normal physiologic reparative process as with any similar tissue failure. Additionally, limited exposure or percutaneous techniques for repair are now available and provide encouraging results.21–23 These techniques do not include any form of tendon debridement, further supporting the concept that the damaged, but not necessarily ischemic, tendon can heal through normal physiologic processes.

Final Words

While open surgical debridement may have been the standard treatment of acute Achilles tendon ruptures in the past, that does not mean that it is the gold standard of patient care now. Numerous studies have shown there is sufficient blood flow along the length of the tendon. Therefore, there is no ischemia and no need to debride the tendon. This point is further supported by the knowledge that Achilles ruptures may heal non-operatively with excellent functional results and low complications. As the research shows, the new standard in care is setting down the blade, taking a break from the OR and having your patients with Achilles tendon ruptures start early weightbearing and ROM.

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Pages: 18 - 21
 
Author(s): 
Paul Dayton, DPM, MS, FACFAS, Sean Harper, DPM, Rachel Egdorf, BS, and Andrea Cifaldi, BS

Dr. Dayton is affiliated with UnityPoint Clinic Foot and Ankle in Fort Dodge, Iowa. He is an Assistant Professor in the College of Podiatric Medicine and Surgery at Des Moines University. Dr. Dayton is a Fellow of the American College of Foot and Ankle Surgeons.

Dr. Harper is affiliated with UnityPoint Clinic Foot and Ankle in Fort Dodge, Iowa.

Ms. Egdorf is a third-year podiatric medical student with the College of Podiatric Medicine and Surgery at Des Moines University.

Ms. Cifaldi is a third-year podiatric medical student with the College of Podiatric Medicine and Surgery at Des Moines University.

References

  1. Lagergren C, Lindholm A. Vascular distribution in the Achilles tendon; an angiographic and microangiographic study. Acta Chir Scand. 1959;116(5-6):491-495.
  2. Carr AJ, Norris SH. The blood supply of the calcaneal tendon. J Bone Joint Surg Br. 1989;71(1):100-101.
  3. Theobald P, Benjamin M, Nokes L, Pugh N. Review of the vascularisation of the human Achilles tendon. Injury. 2005;36(11):1267-1272.
  4. Aström M. Laser Doppler flowmetry in the assessment of tendon blood flow. Scand J Med Sci Sports. 2000;10(6):365-367.
  5. Aström M, Westlin N. Blood flow in chronic Achilles tendinopathy. Clin Orthop Relat Res. 1994(308):166-172.
  6. Hastad K, Larsson LG, Lindholm A. Clearance of radiosodium after local deposit in the Achilles tendon. Acta Chir Scand. 1959;116(3):251-255.
  7. Langberg H, Olesen J, Skovgaard D, Kjaer M. Age related blood flow around the Achilles tendon during exercise in humans. Eur J Appl Physiol. 2001;84(3):246-248.
  8. Langberg H, Bülow J, Kjaer M. Blood flow in the peritendinous space of the human Achilles tendon during exercise. Acta Physiol Scand. 1998;163(2):149-153.
  9. Boushel R, Langberg H, Green S, Skovgaard D, Bulow J, Kjaer M. Blood flow and oxygenation in peritendinous tissue and calf muscle during dynamic exercise in humans. J Physiol (Lond). 2000;524 Pt 1:305-313.
  10. Kubo K, Ikebukuro T, Tsunoda N, Kanehisa H. Changes in oxygen consumption of human muscle and tendon following repeat muscle contractions. Eur J Appl Physiol. 2008;104(5):859-866.
  11. Sheth U, Wasserstein D, Jenkinson R, Moineddin R, Kreder H, Jaglal SB. The epidemiology and trends in management of acute Achilles tendon ruptures in Ontario, Canada: a population-based study of 27,607 patients. Bone Joint J. 2017;99-B(1):78-86.
  12. Deng S, Sun Z, Zhang C, Chen G, Li J. Surgical treatment versus conservative management for acute Achilles tendon rupture: a systematic review and meta-analysis of randomized controlled trials. J Foot Ankle Surg. 2017;56(6):1236-1243.
  13. Twaddle BC, Poon P. Early motion for Achilles tendon ruptures: is surgery important? A randomized, prospective study. Am J Sports Med. 2007;35(12):2033-2038.
  14. Lim CS, Lees D, Gwynne-Jones DP. Functional outcome of acute Achilles tendon rupture with and without operative treatment using identical functional bracing protocol. Foot Ankle Int. 2017;38(12):1331-1336.
  15. Barfod KW, Bencke J, Lauridsen HB, Ban I, Ebskov L, Troelsen A. Nonoperative dynamic treatment of acute Achilles tendon rupture: the influence of early weight-bearing on clinical outcome: a blinded, randomized controlled trial. J Bone Joint Surg Am. 2014;96(18):1497-1503.
  16. Suchak AA, Bostick GP, Beaupre LA, Durand DC, Jomha NM. The influence of early weightbearing compared with non-weightbearing after surgical repair of the Achilles tendon. J Bone Joint Surg Am. 2008; 90(9):1876–83.
  17. Young SW, Patel A, Zhu M, et al. Weight-bearing in the nonoperative treatment of acute Achilles tendon ruptures: a randomized controlled trial. J Bone Joint Surg Am. 2014;96(13):1073-1079. Accessed Feb 11, 2018.
  18. Hutchison AM, Topliss C, Beard D, Evans RM, Williams P. The treatment of a rupture of the Achilles tendon using a dedicated management programme. Bone Joint J. 2015;97-B(4):510-515.
  19. Willits K, Amendola A, Bryant D, et al. Operative versus nonoperative treatment of acute Achilles tendon ruptures: a multicenter randomized trial using accelerated functional rehabilitation. J Bone Joint Surg Am. 2010;92(17):2767-2775.
  20. Bergkvist D, Astrom I, Josefsson PO, Dahlberg LE. Acute Achilles tendon rupture: a questionnaire follow-up of 487 patients. J Bone Joint Surg Am. 2012; 94(13):1229–33.  
  21. Chiu C, Yeh W, Tsai M, Chang S, Hsu K, Chan Y. Endoscopy-assisted percutaneous repair of acute Achilles tendon tears. Foot Ankle Int. 2013;34(8):1168-1176.
  22. Karabinas PK, Benetos IS, Lampropoulou-Adamidou K, Romoudis P, Mavrogenis AF, Vlamis J. Percutaneous versus open repair of acute Achilles tendon ruptures. Eur J Orthop Surg Traumatol. 2014;24(4):607-613.
  23. Hsu AR, Jones CP, Cohen BE, Davis WH, Ellington JK, Anderson RB. Clinical outcomes and complications of percutaneous Achilles repair system versus open technique for acute Achilles tendon ruptures. Foot Ankle Int. 2015;36(11):1279-1286.

The good news is that with a little preparation, leg cramps can be prevented.

1.  STAY HYDRATED
Dehydration causes concentration of the blood and increased lactic acid levels in the muscles. Adequate hydration dilutes the blood and lowers the lactic acid levels in the muscles. While sports drinks are currently in vogue for sports training, regular water is both affordable and appropriate for preventing dehydration problems. The average adult should drink eight to ten 8-ounce glasses of water a day. Drink more if you exercise, or if it's hot or humid. And remember, you don't have to be thirsty to get dehydrated. We exhale up to a pint of water in the form of water vapor each day and our water loss can be very subtle over time so it’s nearly unnoticeable.

2. EAT A BANANA
Bananas are a great source of potassium, which helps to prevent muscle cramps. Eating a banana on race day can help to prevent post-race cramping. But be careful not to eat too many. Too many bananas can cause stomach aches and diarrhea. Too many bananas can also cause irregular heartbeats due to potassium overload.

3. STRETCH
Stretching improves circulation in the muscles and helps to break up adhesions within the muscle fibers. Toe touches and wall push-offs are a great way to stretch those tight calves and hamstrings and break up the muscle adhesions. I recommend three sets of 10 twice daily, but more often if you have the time or inclination. If you have a night splint lying around from your last bout of plantar fasciitis, dust it off and start wearing it again to prevent cramping. If you practice yoga, ask your instructor to help tailor your classes to emphasize the stretching of your feet, leg, and back muscles.

4. DRINK TONIC WATER
Tonic water has quinine, which is also good for preventing cramps. Drink a small bottle (4 ounces) after your run to prevent cramping. Like the caution with bananas, be careful about ingesting too much tonic water because it can cause stomach aches and diarrhea. Quinine in high doses can cause seizures and irregular heartbeats.

5. WEAR GOOD SHOES
If your shoes are worn out, they can transmit the stress of footstrike into your body in abnormal ways and force your muscles to work harder to compensate for the increased stresses. Wearing high-quality, motion-control running shoes that are in good repair (for example, no mid-sole tilting, no holes in the out-soles, etc.) can reduce impact stress and muscle fatigue/overuse injuries.

6. BUY A PAIR OF "GOOD" INSOLES
When an old house settles on its foundation, window frames warp and cracks develop in the walls. Our bodies are like houses and our feet are our "foundations." Our feet are designed to collapse (or "pronate") to absorb the shock of standing, walking, and running. If our feet are excessively pronated, we can be predisposed to developing foot and leg pains because our feet and leg muscles have to work harder to hold us upright and allow us to move forward.

The use of a high-quality insole from a running store may provide enough arch support/motion-control to prevent excessive muscle strains and the resultant cramping. If your symptoms improve but are still present despite the use of athletic insoles, consider seeing a chiropodist for evaluation for custom-molded foot orthotics (molded appliances which provide even more support than athletic insoles).

7. GO ON A RECOVERY RUN/WALK
Going on a light (20-30 minutes) recovery run/walk the afternoon of (or the day after) your long run encourages the movement of blood in the worn-out muscles to help flush out the excess lactic acid. Yoga, lower-extremity aerobic weightlifting (i.e., multiple, rapid repetitions performed with light weights), spinning, or swimming are other activities which could be used as alternative recovery activities after long runs.

Ontario Improving Wound Care for Patients with Diabetes

Province Funding Casts to Treat Diabetic Foot Ulcers

Ministry of Health and Long-Term Care

Ontario is covering the cost of specialized casts to provide more support for patients with diabetic foot ulcers.  

Wound care devices, which include removable, non-removable and total contact foot casts, can significantly improve patients' quality of life by relieving pressure around the heel, ankle and toes so the foot can properly heal. These casts will be made available free of charge at eligible locations such as foot and wound care clinics, specialized programs for diabetes and community health, complex continuing care and rehabilitation centres.

The province is also supporting wound care training and education for health care workers, which will include specialized skills development in diabetic foot ulcer management.

Ontario's plan to create fairness and opportunity during this period of rapid economic change includes a higher minimum wage and better working conditions, free tuition for hundreds of thousands of students, easier access to affordable child care, and free prescription drugs for everyone under 25 through the biggest expansion of medicare in a generation.
 

Quick Facts

  • Ontario is providing more than $8 million over three years to provide three types of foot casts, also referred to as offloading devices, to treat diabetic foot ulcers. These devices include removable, non-removable and total contact foot casts which can cost between $150 and $620.
  • This funding followed Ontario’s acceptance of the Ontario Health Technology Advisory Committee’s recommendations to fund three types of offloading devices.
  • The province is also investing more than $50,000 this year to support 14 health care specialists across the province to attend the Wounds Canada Conference for hands-on training and education. This funding is part of the larger wound care strategy.
  • Offloading devices can be an effective treatment tool for diabetic foot ulcers and can significantly improve patient outcomes and reduce the risk of amputation.

Additional Resources

Quotes

“Making it easier for patients to access the services they need is a key priority for our government. Diabetic foot ulcers can be extremely debilitating, and if not properly treated, can negatively impact a person’s health and quality of life. We are making these wound care devices available free of charge to patients who need them in order to improve their healing and subsequently, their overall health.”

Dr. Eric Hoskins

Minister of Health and Long-Term Care

“The government's announcement today is excellent news for persons with diabetes who suffer from diabetic foot ulcers. The funding of offloading devices (pressure relieving), will prevent amputations and the devastating suffering and cost that result from them. We are proud that Ontario is the first province to provide universal funding for offloading devices for the treatment of foot ulcers and we encourage all other provincial governments across Canada to implement this evidence based cost saving therapy. The announcement is the culmination of a meaningful partnership between organizations representing nurses, physicians, other health professions and the public.”

Doris Grinspun, CEO, Registered Nurses' Association of Ontario (RNAO), and Mariam Botros, CEO, Wounds Canada

“Amputations are one of the most feared consequences of diabetes. Diabetes Canada recognizes the Government of Ontario’s leadership in providing public funding for offloading devices, which treat diabetic foot ulcers and prevent amputations. Diabetes Canada encourages the Government of Ontario to continue working on this issue, and encourages other provinces to follow Ontario’s leadership in helping Canadians living with diabetes with their foot care.”

Amanda Thambirajah

Director of Government Relations, Ontario, Diabetes Canada

December 14, 2017
Category: Uncategorized
Tags: Untagged
Diabetes in Real Life

Daily foot care can prevent later problems

 
What should a person with diabetes be doing on a daily basis to ensure good foot health?

Neuropathy, vasculopathy and a faulty immune system affect the feet of patients with diabetes and can lead to needless and preventable foot pathology. People with diabetes on a daily basis should be visually and manually inspecting both their feet and their shoes. The foot inspection is to identify a crack in the skin or a locally red swollen or warm area. The shoe inspection is to identify any defect in the shoe itself and any foreign objects in the shoes.

People with diabetes who notice dry skin on their feet or legs due to autonomic neuropathy should apply a urea-based moisturizing lotion. They also need to wear appropriate socks and shoes for their activities. They should practice preventive foot care to avoid developing foot ulcers from the combination of sensory neuropathy and mechanical, chemical or thermal trauma. Foot ulcers can lead to infection, hospitalization and the most dreaded complication of the diabetic foot, amputation. People with diabetes have a list of recommended tasks they are to perform daily to manage their foot health. They should be aware of any changes to their foot health, and if they find a problem, they should seek professional attention promptly.

Every person with diabetes should have a yearly comprehensive diabetic foot exam by their foot specialist that includes a monofilament test.

What are the most common foot problems?

A quick list of the most common foot problems includes those of the nails; keratosis, or corns and calluses; bone and joint deformities; and nerve and heel pain. No matter what the foot problem, visiting a podiatrist for a comprehensive diabetic foot exam, X-rays and laboratory tests is the first step to resolution.

The most common foot problem involves the toenails, which can be thick or discolored, ingrown or deformed. Trimming toenails can be difficult and often not realistically possible for people with diabetes, who should seek professional care for nail trimming and medical treatment of mold yeast or fungal nail infections. I have witnessed patients with diabetes who unknowingly have cut the end of their toes off while trimming their nails. How does this happen? The reasons include poor vision, poor lighting, poor eye-motor coordination, and inappropriate and nonsterile instruments. A person with diabetes who has nail problems and poor vision should have professional foot care by a chiropodist.

 

Endocrine Today, November 2017

In this issue, Susan Weiner, MS, RDN, CDE, CDN, talks with podiatrist Mark Hinkes, DPM, about foot problems that commonly affect people with diabetes.

Prevention & Recovery

Why orthotics make for happy feet

From pain reduction to performance enhancement, show your feet some love with orthotic inserts.

A trip to see a Canadian Certified Pedorthist is your first step to happy, healthy feet. These experts in lower-limb anatomy and biomechanics, assess your gait and specialize in making custom foot orthotics and modified footwear. From feet, back and knee aches, to performance and comfort upgrades, your lifestyle and medical history are considered. "We look at posture, the range of motion in your joints and the activities you enjoy participating in, to see if your biomechanics are contributing to your pain," says Peter Morcom, President of the Pedorthic Association of Canada. After a thorough assessment, "we use video to show you exactly what your gait looks like, and how and if modified footwear can help."

When it comes to foot orthotics, there are two main functions. The first helps to decrease excess motion in an over-pronated foot, often called a flat foot. The second, most commonly used with high rigid arches, provides equal weight distribution and shock absorption. Foot orthotics come in all shapes and sizes, and are made from a variety of materials, from plastic to EVA foam to graphite. While any foot type can benefit from an orthotic, not every foot will need one. An appointment with a Canadian Certified Pedorthist is the easiest way to assess your challenges.

Off-the-Shelf Versus Custom

If you're looking to increase comfort, performance, and even if you're experiencing some pain, a simple, off-the-shelf orthotic might be your best bet, and your quickest solution. The more affordable cost is also a plus, ranging between $30-$100. "These products can be a great test, or trial period, before you go the custom route," says Morcom. But because there are many different products on the market, a consultation with a Canadian Certified Pedorthist is still an important part of understanding which type of orthotic is best for you. Just like custom options, off-the-shelf products can vary in arch-height, amount of cushioning and stiffness or rigidity.

With custom orthotics, you get better control and patient specificity. Once your gait and lower limb assessment is complete, a pedorthist will cast your foot using either plaster, a foam mold or 3D laser scan. While off-the-shelf and custom foot orthotics may look similar in the end, the precision that goes into the casting process allows for lots of specialized additions. "There are benefits like forefoot posting, for example, which can change the actual angle your foot rests at, or metatarsal pads and many other personalized adjustments," says Morcom. While the cost is significantly higher for custom, $350-$650, they are often covered by benefit plans and have a much longer lifespan.

The Feet Sheet

  Off-the-shelf Custom
 Cost 

 $30-$100

 Not covered by benefits

 $350-$650

 Often partially or fully covered by benefits

 Life  Span

 1 year

 5+ years
 Wait  Time  Immediate  Two weeks from assessment




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