This article is more than 5 years old. Information may no longer be current.
Surgical and nonsurgical options prove effective for Achilles tendon ruptures
An Achilles tendon rupture can result in weeks of therapy, bracing or immobilization, depending on which treatment an individual with this type of injury undergoes and no matter the treatment option selected, orthopaedists tell their patients that it will detract from their participation in normal physical activities and will require several weeks of follow-up physical therapy.
“There are several factors that may lead to Achilles tendon ruptures. A previous repetitive microtrauma, particularly in basketball players, tennis players, gymnasts, soccer players, runners, track and field athletes, and dancers, can create tremendous stress on the tendon and is one of the common mechanisms of the Achilles tendon rupture,” Prof. Mahmut Nedim Doral, MD, PhD, of Ankara, Turkey, told Orthopaedics Today Europe.
The incidence of Achilles tendon (AT) ruptures is increasing annually, according to a retrospective study by Heyes and colleagues at Ulster Hospital Dundonald, in Ulster, United Kingdom, published this year, which included results for 1,075 patients who were expected to have an AT rupture between 1996 and 2008.
The findings showed an increase in AT ruptures from about 7 incidents per 100,000 people in 1996 to 35 incidents per 100,000 people in 2008 with the peak incidence in individuals 40 years to 49 years old. Men had a higher incidence of ruptures than women with an almost 3:1 ratio, based on the results.
Most of the individuals studied with a torn AT participated in sports with vigorous leg push off motions, the researchers noted.
Individuals older than 30 years are statistically more at risk for AT ruptures than younger individuals, according to Doral.
Nicola Maffulli, MD, PhD, FRCS, whose group was the first to describe the beneficial effects of early weight bearing and mobilization after AT rupture, told Orthopaedics Today Europe a patient with an AT rupture can opt for nonsurgical or surgical treatment to correct the injury. He tends to offer a minimally invasive surgical procedure to patients who opt for surgery. A traditional surgical technique that involves a large, open incision several inches long in the back of the leg is less superior for a rupture, Maffulli said.
“For an acute repair, I use a minimally invasive technique under local anesthesia by local infiltration. It involves a total of seven stab wounds and we use absorbable material, in a very strong configuration, as we have shown in biomechanical studies. We have obviated one of the perceived problems of such procedures, namely injury to the sural nerve, by using local anesthesia by local infiltration. Even in athletes, I have not undertaken an open surgical repair of an acute rupture for close to 15 years,” he said.
Percutaneous repairs like those that Maffulli described are typically successful and can minimize the infection rate and complications, Joseph Alsousou, LMSSA Lon, MD, MRCS Ed, D-Phil, said. But, as with any surgery, the possibility of infection is always there, he said noting the skin in that area of the leg is of poor quality, so there is always a risk of skin breakdown or wound breakdown, which may lead later on to infection or tissue deterioration beneath the skin.
Furthermore, because the surgical incisions for a repair are so close to the sural nerve, there is a risk for nerve damage, as well, according to Alsousou.
“But, with careful planning and concentration on the nerve’s existence and relationship to the tendon, you can avoid this complication easily. Obviously, using a sterilizing technique while you are operating on the tendon and respecting the tissue when you are opening or doing a percutaneous repair is paramount to reducing the risk of breakdown and infection,” Alsousou told Orthopaedics Today Europe.
However, in terms of functional outcomes, there is no evidence in the literature that surgery for an AT rupture has an advantage over nonsurgical repair, according to studies by Victor Valderrabano, MD, PhD, and colleagues Claudio Rosso, MD, MSc, Head of Sports Orthopaedics Unit, and Sebastian Gehmert, MD, a resident and researcher, at University Hospital of Basel, in Basel, Switzerland.
“Surgical repair of an Achilles tendon injury significantly reduces the risk of re-rupture compared with nonsurgical treatment as supported by a meta-analysis of 12 trials involving 844 patients” by Khan and colleagues, Valderrabano told Orthopaedics Today Europe. “However, no definite evidence is provided that surgical repair is associated with any benefit in terms of functional outcome.”
Nonoperative or conservative management of an AT rupture involves bracing or casting immediately after the injury for several weeks. Alsousou said in his clinic the general protocol for conservative management involves 3 weeks of casting and then transitioning the patient to a brace for an additional 3 weeks.
“The strongest evidence so far for the nonoperative or conservative management is the Sheffield regimen. You immobilize a tendon in a device for 3 weeks and then gradually start physical therapy, build-up therapy for a period of time, and then rehab is generally 12 weeks,” Alsousou said. “We use exercises of the foot and ankle tendon to strengthen the whole gastrocnemius and Achilles tendon unit.”
While patients may opt for nonsurgical management, most sources agreed professional athletes almost always choose surgery and are placed on an accelerated rehabilitation program to return to play sooner.
Doral prefers a percutaneous surgery for athletes with a ruptured AT and immediately afterwards places them on a standard physical therapy program.
“The early active rehabilitation protocol is started the day after the surgery. Full weight-bearing mobilization is allowed as tolerated without using a brace, splint or special shoe. Neuromuscular exercises for the ankle and lower extremity are performed in the first week, and resistance and gentle active stretching exercises are started at the end of 6 weeks after the surgery. In the case of elite athletes, a sports-specific program is designed at the third month after the surgery,” he said.
A study Doral recently conducted showed early weight bearing and intensive rehabilitation following surgery would lead to increased muscle strength and lower extremity functional level on the affected side.
According to Alsousou, most athletes will opt for the percutaneous surgical repair because it requires less time in a cast and less immobilization, which leads to less atrophy of the surrounding muscle.
“They want to restore the muscle-tendon unit function as soon as possible and start moving the tendon as soon as possible. That will obviously give athletes a slight edge when it comes to training and going back straight to their competitive level,” he said.
For any AT repair surgery, most of the sources for this Cover Story said the use of a graft matrix has not been scientifically proven to aid in the healing process.
Despite what scaffold manufacturers say, Maffulli said the evidence is lacking for their use. Using the devices can lead to longer operation times, higher rates of complications and increased costs, and Maffulli said he never uses these products for a straightforward, uncomplicated primary acute AT repair.
“Despite what we are led to believe by the manufacturers, there is really no evidence that augmentation in any form, including using a GraftJacket [Wright Medical Technology] or similar devices or an autologous tendon graft or a turndown flap, improves the outcome following a surgical repair of an acute rupture,” Maffulli said.
However, Valderrabano said there are instances when biological scaffolds, such as grafts or allograft tissues, can be helpful in the healing process.
“Since surgical repair of an Achilles tendon is not associated with any benefit in terms of functional outcome, biological scaffolds are (only) appropriate when the tendon defect exceeds 5 cm or cells (stem cells) are applied,” he said.
One treatment to repair the ruptured AT for which physicians have differing opinions is platelet-rich plasma (PRP) injections to increase healing, an approach that is gaining some popularity.
Alsousou defended the PRP treatment, but said additional studies, such as adequately-powered clinical trials, are needed to provide level 1 evidence of its clinical application.
In 2012, Alsousou presented a study at the British Orthopaedic Association Annual Congress that showed two groups of patients with AT ruptures who received PRP injections had larger and thicker tendons at 24-weeks follow-up than controls.
“We have studied the effects of platelet-rich plasma in a laboratory on Achilles tendon cells, and we found PRP can promote migration, promote protection of the cells in a hydroxic environment that follows a rupture, and it promotes the proliferation of cells. We also studied the effect of plasma as a whole on Achilles tendon tissues taken from patients who ruptured their tendons, and we found, again, the PRP with its cellular components (platelet and white cells) encourages migration of fibroblasts and tenocytes to the rupture area and increased the number of cells compared to a control,” he said.
Doral spoke favorably about the use of platelets and reported using platelet-rich growth factor (PRGF) treatments as standard protocol for AT repair.
“It plays an important role in the process of wound and soft tissue healing,” he said. “Therefore, I prefer biologic agents rather than steroids, especially in tendon and ligament problems. I have an experience of over 200 patients treated by endoscopy-assisted minimally invasive technique with PRGF injection. There were no re-ruptures observed with high rate of satisfaction.”
There are signs that PRP injections and other growth factors can activate and regulate cellular responses, according to a meta-analysis by Rosso and Valderrabano.
“Insulin-growth-like factor-1 (IGF-1) has been reported to be up-regulated at the inflammatory phase stimulating migration and proliferation of fibroblast and inflammatory cells. In addition, IGF-1 has been reported to limit inflammation and accelerate recovery after Achilles tendon injury. Moreover, IGF-1 enhances collagen synthesis during the stage of remodeling. Increased cell proliferation and synthesis of various ECM [extracellular matrix] components, especially collagen I, during the remodeling phase has been reported for application of PDGF [platelet-derived growth factor] in a dose dependent manner. The fact that platelets release growth factors suggests a positive influence in clinical situations where rapid healing and tissue regeneration is required,” Valderrabano said.
Maffulli said the evidence for platelet-rich treatments has yet to be provided and they seem to be more of a fad for surgeons to use. In addition, the evidence is squarely against the use of PRP therapy to help repair an Achilles tendon.
“Here we are facing enormous commercial and media pressure. The evidence is squarely against the use of PRP injections in the management of a torn Achilles tendon. Indeed, some authors have shown that such injections can actually be detrimental. Frankly, if I were to tear my Achilles tendon, I would choose a good surgeon instead of a surgeon who used the latest fads,” Maffulli said. – by Robert Linnehan
- References:
- Heyes G. Ann Orthop Rheumatol. 2014;2:1017.
- Khan RJ. Cochrane Database Syst Rev. 2010;doi:10.1002/14651858.CD003674.pub4.
- For more information:
- Joseph Alsousou, LMSSA Lon, MD, MRCS Ed, D-Phil, can be reached at Nuffield Department of Orthopaedic Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, OX3 9DU, United Kingdom; email: josephalsousou@doctors.org.uk.
- Mahmut Nedim Doral, MD, PhD, can be reached at the Department of Orthopaedics and Traumatology, Faculty of Medicine, Hacettepe University, 06100, Ankara, Turkey; email: mndoral@gmail.com.
- Nicola Maffulli, MD, PhD, FRCS, can be reached at the Centre for Sports and Exercise Medicine, Barts and the London School of Medicine and Dentistry, Mile End Hospital, 275 Bancroft Road, London E1 4DG, United Kingdom; email: n.maffulli@qmul.ac.uk.
- Claudio Rosso, MD, MSc, and Victor Valderrabano, MD, PhD, can be reached at the Orthopaedic Department, Osteoarthritis Research Center Basel, University Hospital of Basel, Spitalstrasse 21, 4031 Basel, Switzerland; email: claudio.rosso@usb.ch; email: victor.valderrabano@usb.ch.
Disclosures: Alsousou, Doral, Maffulli, Rosso and Valderrabano have no relevant financial disclosures.
Does scientific evidence support PRP injections as a treatment option for Achilles tendon ruptures?
Limit use to clinical trials
Basic science studies have shown the healing tendon is responsive to local application of growth factors and describe their role in the platelet alpha granules in tendon regeneration. Releasate from platelet concentrates stimulated gene expression of the matrix molecules, tendon cell proliferation, synthesis of angiogenic and other growth factors, and activated circulation-derived cells that play a key role in the tissue healing process. Preclinical in vivo evidence mostly supports the use of platelet-rich plasma (PRP) for Achilles tendon (AT) tears although some trials show the benefit may be limited to the early healing phases.
However, these studies present some important limitations, being carried out in animals, using allogenic PRP, and exploring the effects in acute tear models in otherwise healthy tendons. This could make transferability of the results to the human setting unreliable. Despite support of the published preclinical studies, these promising results have not been translated into clinical practice yet. Only a few studies explored the role of PRP in treating AT rupture, with contradictory findings. Beside some initial promising anecdotal reports, the most robust study, a randomized trial, showed no benefit from PRP surgical augmentation and suggested a detrimental effect after 1 year.
Contradictory results among studies may be explained by the many variables related to the platelet concentrates used and their administration. It is possible future studies will identify the best PRP formulation and application modality and thus optimize this biological approach to favor tendon healing. Until there is stronger evidence, PRP should be used as augmentation for surgical treatment of AT ruptures only within clinical trials.
Giuseppe Filardo, MD, PhD, is an orthopaedic surgeon and researcher at Rizzoli Orthopaedic Institute - II Clinic, Biomechanics Lab, in Bologna, Italy.
Disclosure: Filardo has no relevant financial disclosures.
Evidence remains unclear
Platelet-rich plasma is a much-discussed topic in orthopaedic surgery and evidence is not clear on many indications. In a meta-analysis in the Journal of Orthopaedic Research published by our group, we found in an animal model, there was benefit using it in Achilles tendon ruptures, but not in Achilles tendinopathies. In a recent retrospective evaluation, the benefit of platelet-rich plasma (PRP) in a human Achilles tendon (AT) rupture model was not shown. However, in an accepted publication, we saw a benefit of its use in small to medium rotator cuff tears after surgical repair. Thus, we do not routinely use PRP in acute AT ruptures with nonoperative or operative treatment, but we do utilize PRP in chronic ruptures after the surgical procedure.
Claudio Rosso, MD, MSc, is an orthopaedist and the head of Sports Orthopaedics in the Orthopaedic Department at University Hospital Basel, University of Basel, in Basel, Switzerland.
Disclosure: Rosso is a consultant to DePuy Synthes Mitek and receives research support from DePuy Synthes Mitek, Arthrex and Smith & Nephew.
Some healing potential demonstrated
Platelet-rich plasma (PRP) has become an important player in the treatment of several sports-related pathologies where tendinopathies and tendon ruptures are frequent. Thus many orthopaedic surgeons worldwide use PRP in their daily practice. A number of basic science studies clearly showed PRP can improve healing of different tissues, especially tendons. In particular, it influences the early phase of tendon healing and results in an ultimately stronger mechanical resistance.
Unfortunately translation into clinical application of PRP provides conflicting findings. For instance, results in the literature for PRP used in rotator cuff tears or patellar tendinopathy show pain reduction and improved tissue healing, whereas its use in Achilles tendinopathy showed no advantage.
Such conflicting results can be explained by non-standardized PRP preparations that cause PRP to differ in its concentration and activation. The optimal PRP preparation should be a 5 times to 8 times concentration in activated form. Another reason why results can differ is the quality of the studies. The most important study of PRP in Achilles rupture is a randomized single-blind study that is clearly underpowered, with only 14 patients in the control group.
Thus we cannot suggest or dissuade the use of PRP in Achilles tendon ruptures, but should encourage deeper study of this fascinating area of regenerative medicine.
Pietro Randelli, MD, is professor at University of Milan and a member of the Orthopaedics Today Europe Editorial Board.
Disclosure: Randelli has no relevant financial disclosures.