SLR - August 2017 - Tyler J. Veldkamp
Reference: Westin O, Nilsson Helander K, Grävare Silbernagel K, Möller M, Kälebo P, Karlsson J. Acute Ultrasonography Investigation to Predict Ruptures and Outcomes in Patients with an Achilles Tendon Rupture. Orthop J Sports Med. 2016 Oct 14;4(10)Scientific Literature Review
Reviewed By: Tyler J. Veldkamp, DPM
Residency Program: Hennepin County Medical Center, Minneapolis, MN
Podiatric Relevance: The authors of this study looked at whether ultrasound can be used to predict the risk of reruptures and overall outcomes after treatment of an acute Achilles tendon rupture. This study offers an additional parameter when assessing an acute rupture and whether to treat conservatively versus operative intervention.
Methods: This was a randomized controlled study involving 45 patients, mean age of 39 years old, with acute Achilles tendon ruptures. Patients were split into surgical and nonsurgical treatment groups. Exclusion criteria were diabetes mellitus, previous Achilles tendon rupture, other lower-leg injuries, immunosuppressive therapy and neurovascular disease. Ultrasound of the ruptured Achilles tendon was performed within 72 hours from the initial injury, and diastasis between the tendon ends was documented. Those in the surgical category underwent open direct repair with end-to-end modified Kessler technique. All patients underwent standard rehabilitation programs. Reruptures were documented, and the patient’s functional outcomes were measured 12 months after the injury using the Achilles tendon Total Rupture Score as well as measuring heel-rise height.
Results: Patients with a diastasis of >10 mm treated nonsurgically had a higher degree of rerupture with three out of four patients in this group suffering from a rerupture. In the nonsurgical group, there were significantly worse outcomes in patients with a diastasis of >5 mm in terms of patient-reported outcomes using the Achilles tendon Total Rupture Score and heel-rise height at 12 months compared with the group with a lesser degree of tendon separation.
Conclusion: Ultrasound can be a useful tool to predict the risk of rerupture and greater degree of functional deficit in acute Achilles tendon ruptures. It can be implemented within a physician’s clinical treatment algorithm for deciding whether a patient will benefit from surgical intervention after an acute Achilles tendon rupture versus conservative treatment. This article only adds to the discussion of operative versus nonoperative treatment of acute Achilles tendon ruptures. It gives distinct parameters, measurable with ultrasound, that lead to worse patient outcomes in nonoperative treatment. While the study does not have robust numbers, it correlates with other literature pointing toward diastasis of greater than 5 mm with worse outcomes. This adds to the argument that 5 mm suggests nonapposition of the tendon ends and hence should be a recommended cutoff point to offer surgical management. Overall, the final decision will come to the surgeon along with other patient factors, but ultrasound can be an added tool in the treatment algorithm of Achilles tendon ruptures.