Percutaneous Repair in Patients Aged 50 Years and Older Is Associated With Good Outcomes in Acute Achilles Tendon Rupture

Abstract

Background:

The incidence of Achilles tendon ruptures in patients aged ≥50 years is increasing worldwide with an aging population that is increasingly physically active and taking up recreational activities, such as pickleball and paddleball. The aim of this study was to assess patient-reported outcomes in patients aged ≥50 years with a complete Achilles tendon rupture comparing percutaneous repair to non-operative management over 12 months.

Methods:

This is a single-centre prospective cohort study with patients recruited over a 10-year period. Patients filled an Achilles tendon Total Rupture Score (ATRS) at 3-month, 6-month and 12-month intervals.

Results

173 patients were included; 70 patients were managed operatively and 103 patients were managed non-operatively. At 12 months, 50 patients (71.4%) in the operative group and 57 patients (55.3%) in the non-operative group completed the ATRS score. At 3-month and 6-month intervals, there was no statistically significant difference in average ATRS scores (P = .23 and P = .32, respectively). At 12 months, the average ATRS score in the operative group was 89.9 (SD 11.1 and 95% CI 86.7-93.1), with 74.3 (SD 19.5 and 95% CI 69.1-79.5) in the non-operative group; this was statistically significant (P = .001). The biggest improvement in the operative group was seen in questions related to running, jumping and hard physical labour.

In the operative group, 1 patient sustained a re-rupture (1.4%), with 1 patient sustaining a pulmonary embolism (1.4%). In the non-operative group, 3 patients sustained re-ruptures (2.9%) and 2 patients (1.9%) sustained a pulmonary embolism.

Conclusion:

Patients aged ≥50 years who undergo percutaneous repair had higher ATRS scores at 12 months compared with non-operative care. Percutaneous repair appears to be a valid option for management of these injuries in an increasingly active population aged ≥50 years.

Level of Evidence:

Level II, prospective cohort study.

Introduction

The incidence of Achilles tendon ruptures in the United Kingdom is approximately 8 per 100000 people per annum. ¹ The Achilles tendon is the largest in the body with critical functions for walking and more explosive power activities. ² As age increases, the risk of rupture increases, with males at a greater risk. ³

From ≥50 years, patients typically participate in periodic physical activity and are colloquially named as ‘weekend warriors.’ ⁴ With an increasingly ageing population worldwide and more patients aged ≥50 years engaging in physical activity, the rate of Achilles tendon ruptures in this population is expected to increase. ⁵ Typically, operative intervention is reserved for younger patients or professional athletes. ⁶ Despite an ageing population who are increasingly physically active, very few studies have looked at the outcomes of patients aged ≥50 years comparing operative vs non-operative management.

The primary aim of this study was to assess any difference in patient-reported outcome measures using the Achilles tendon Total Rupture Score (ATRS) between patients managed operatively with a percutaneous repair technique vs patients managed non-operatively who are aged ≥50 years.

Methods

This is a single-centre prospective cohort study performed at University Hospital North Midlands (UHNM) NHS Trust in the United Kingdom, one of the largest teaching hospitals in the United Kingdom. Patients were recruited over a 10-year period from 2010 to 2020. Any patient diagnosed with an acute complete Achilles tendon rupture who was aged ≥50 years at the time of injury was eligible for inclusion. Acute was defined as <4 weeks from the date of injury to the date of operation or decision to manage non-operatively. Partial injuries were therefore not included. A priori study size was not calculated given the lack of evidence in this age group.

Patients who were managed non-operatively were managed in a VACOped boot (OPED). If they were managed operatively, this was performed using a percutaneous technique. Patients who were managed with an open repair or converted from a percutaneous to an open repair were not included.

This was a clinical diagnosis by experienced foot and ankle consultants specialising in the management of Achilles tendon ruptures with ultrasound scan used in cases of diagnostic uncertainty. A shared decision-making process was conducted based on factors such as the patient’s background history, activity levels and patient preferences. The patient selection was accepted as a source of selection bias.

For non-operative management, patients were managed using a protocol in the VACOped boot as outlined in Figure 1. From week 0 onward, patients could mobilise full weightbearing in the boot. At week 0 to week 3, patients were placed into an equinus position at 30 degrees of plantarflexion within the boot supported by wedges. At week 3 to week 6, the boot was adjusted into a mid-equinus position in 15 degrees of plantarflexion. At week 6 to week 8, the position of the boot was changed to a neutral position and patients used a flat-sole shoe with the boot to mobilise. After week 8, the boot was removed and patients weaned back into normal footwear. Venous thromboembolic prophylaxis in the form of subcutaneous heparin was prescribed for patients whilst they were in the boot. For more detail, the rehabilitation programme for non-operative management is included in Figure 2.

Figure 1.

VACOped Protocol: VACOped boot protocol with position of boot from week 0 to week 8. Week 0-3 equinus: 30 degrees plantarflexion angle. Week 3-6 mid-equinus: 15 degrees plantarflexion angle. Week 6-8 plantigrade: 0 degrees plantarflexion angle (adapted with permission from co-author N Grocott).

Figure 2.

Achilles tendon non-operative rehabilitation protocol (adapted with permission from co-author N Grocott).

If patients were managed operatively, the operation was performed by an experienced foot and ankle consultant under general anaesthetic using a percutaneous technique. Open repairs were rarely performed given the reliable reproducibility of the percutaneous technique, and open repairs were often reserved for revision procedures.

The patient was placed in a prone position with the feet hanging off at the end of the operating table. Intravenous antibiotics were given as per local protocol for prophylaxis. The contralateral leg was fitted with an antiembolic stocking and Flowtron. On the operative leg, an above-knee pneumatic tourniquet was applied with padding and an exclusion drape. The limb was then prepped with alcoholic chlorhexidine, and the tourniquet was inflated to 250 to 300 mm Hg based upon the patient’s blood pressure.

Once the patient had been prepped, the level of the tendo-Achilles rupture was palpated and a 2-cm transverse incision was used to identify both ruptured ends. Approximately 9 cm proximal to the rupture site, a 2-cm longitudinal incision was marked out on the lateral aspect of the tendon. The reason for this was to allow for dissection down to the tendon in an attempt to visualise and protect the sural nerve, minimising injury to the sural nerve. This technique is therefore a modification of the technique described by Carmont and Maffulli ⁷ with the addition of the 2-cm proximal lateral incision.

A Mayo needle was then loaded with a 4-strand (2 double loops) No. 1 Maxon suture (Medtronic). The 2 double loops were cut to create 4 strands. In the proximal tendon, 4 strands of Maxon suture with the Mayo needle were passed from lateral to medial in a transverse fashion approximately a few centimetres from the rupture site with a stab incision used medially for passage of the Mayo needle. A modified Bunnell construct was used for the proximal tendon stump. Therefore, 2 ends of 4-strand Maxon suture were passed into the proximal tendon stump rupture site, meaning 8 strands of Maxon suture in total were present in the proximal tendon stump.

The distal stump of the tendon was then passed through stab incisions marked out in the distal stump of the tendon. The stab incisions were marked just above the palpable insertion of the tendon on the calcaneal tuberosity on the medial and lateral side of the tendon depending on the rupture site. Another 4-strand No. 1 Maxon suture was passed lateral to medial transversely with the Mayo needle. The lateral sutures were passed from distal to proximal up to the distal tendon stump through the transverse incision; the same was performed for the medial sutures. This therefore created a modified Kessler type construct for the distal tendon stump. The free ends of the suture were pulled to ensure satisfactory hold in the tendon. Therefore, 8 strands of Maxon suture were present in the distal tendon stump. The foot was then maximally plantarflexed and the suture ends from the proximal and distal stumps were tied on the medial side with good tension after 2 throws and an opposing throw to lock the suture. The lateral side proximal and distal ends were then tied together in the same fashion. Therefore, in total, 8 strands crossed the rupture site. The suture ends were trimmed and then the skin was closed with subcuticular 3-0 Monocryl sutures (J&J) and Steri-Strips (3M) to the stab incisions.

Following the repair, patients were placed into a bi-valved below-knee cast with a plantarflexion angle of 45 degrees. Whilst in the cast from week 0 to week 6, patients could partially weight bear approximately 50% of their body weight with venous thromboembolic prophylaxis prescribed in the form of subcutaneous heparin. At week 3 to week 6, the anterior half of the cast was removed with the posterior half remaining and patients continued to partially weight bear. At week 6, the anterior half of the cast was removed; therefore, no cast remained. Patients at this point could discontinue the venous thromboembolic prophylaxis and begin more intensive physiotherapy as described in Figure 3.

Figure 3.

Achilles tendon percutaneous repair rehabilitation protocol (adapted with permission from co-author N Grocott).

The ATRS score was used as this is a validated score to assess outcomes of patients managed both operatively and non-operatively. ⁸ The minimal clinically important difference (MCID) has been defined as 10 points with the score from 0 to 100. ⁹ A score of 100 suggests no limitations across many different parameters.

At the time of patient discussion, 100% of patients agreed to complete the ATRS score at the required time intervals. Patients were followed up in a dedicated clinic with experienced physiotherapists. The ATRS was often filled in person with patients. However, if time was unavailable in the clinic, the ATRS was completed by postal service.

Complications that were assessed using patient correspondence included deep vein thrombosis, pulmonary embolism, superficial wound infection, deep infection, re-rupture and sural nerve injury. Ethical approval was sought from the local audit department. Descriptive data analysis was performed along with an independent Student t test to compare the average ATRS scores of percutaneous repair vs non-operative management at the 3 time points established (3 months, 6 months and 12 months) either post-injury or post-surgery. Statistical significance was deemed if the P value was less than .05 and was performed using SPSS (IBM). Analyses of ATRS at each time point were conducted on patients who completed ATRS at that visit; missing outcome data were present (see Table 1) and no imputation was performed. If patients were lost to follow-up, their ATRS scores could not be included at the time points but their complications were still assessed irrespective if they filled in the ATRS score or not.

Table 1.

Summary of the Number of Patients Who Completed the ATRS Score at Each Time Point.

	3 mo	6 mo	12 mo
Operative, n (%)	48 (68.6)	48 (68.6)	50 (71.4)
Non-operative, n (%)	70 (70.0)	60 (58.3)	57 (55.3)

Results

Figure 4 summarises the eligibility and total recruited in each group. In total, 173 patients were included, with 70 in the operative group and 103 in the non-operative group. In the operative group, the average age was 59.2 years (SD 7.5 and 95% CI 57.4-60.1). The average days between the date of injury to operation was 10 days (95% CI 8.8-12.2). In the operative group, 60 patients were male (85.7%) with 10 female patients. In the non-operative group, the average age was 63.6 years (SD 9.5 and 95% CI 61.8-65.5). Eighty-two patients were male (79.6%), with 21 female patients. There was a statistically significant difference in the ages between the operative and non-operative groups (P < .001).

Figure 4.

STROBE flow diagram summarising the eligibility and recruitment into each group.

In terms of background history, in the operative group the average Charlson Comorbidity Index (CCI) ¹⁰ value was 1.78; in the non-operative group, the average CCI value was 2.46. This difference in the CCI was statistically significant (P < .001). In the operative group, 5.8% of patients were smokers at the time of injury as compared to 9.7% in the non-operative group. In the operative group, all patients were independently mobile; in the non-operative group, all except 1 patient could mobilise independently, with the one patient requiring 2 crutches to mobilise.

When comparing the patients who completed the ATRS at 12 months, in the operative group the average CCI was 1.8 and in the non-operative group this was 2.3; this difference was statistically significant (P < .05). When comparing ages in the patients who completed the ATRS at 12 months, in the operative group the average age was 59.9 years (SD 7.7 and 95% CI 57.7-62.1), whilst in the non-operative group the average age was 64.3 years (SD 9.1 and 95% CI 61.9-66.7). The difference in ages was statistically significant (P < .01).

Table 1 summarises the number of patients who completed the ATRS at each time point. At 12 months, 50 patients (71.4%) in the operative group and 57 patients (55.3%) in the non-operative group completed the ATRS score.

Figure 5 demonstrates the ATRS score per question at 3 months in both operative and non-operative groups. The mean total ATRS score in the operative group was 46.3 (SD 20.4 and 95% CI 40.4-52.2) and 51.0 (SD 21.5 and 95% CI 45.9-56.1) in the non-operative group. At 3 months, there was no statistically significant difference in the ATRS scores (P = .23).

Figure 5.

ATRS score per question at 3 months in operative (n = 48) and non-operative (n = 70) groups (error bars show SD). ATRS, Achilles tendon Total Rupture Score.

Figure 6 demonstrates the ATRS score per question at 6 months. The mean total ATRS score in the operative group was 71.4 (SD 19.8 and 95% CI 65.7-77.1) and 67.8 (SD 17.6 and 95% CI 63.3-72.2) in the non-operative group. At 6 months, there was no statistically significant difference in the ATRS scores (P = .32).

Figure 6.

ATRS score per question at 6 months in operative (n = 48) and non-operative (n = 60) groups (error bars show SD). ATRS, Achilles tendon Total Rupture Score.

Figure 7 demonstrates the ATRS score per question at 12 months. The mean total ATRS score in the percutaneous repair group was 89.9 (SD 11.1 and 95% CI 86.7-93.1), with 74.3 (SD 19.5 and 95% CI 69.1-79.5) in the non-operative group. This, therefore, reached the MCID of 10 points in favour of the operative group and this difference was statistically significant (P < .001). In every question at 12 months, the operative group had improved outcomes.

Figure 7.

ATRS score per question at 12 months in operative (n = 50) and non-operative (n = 57) groups (error bars show SD). ATRS, Achilles tendon Total Rupture Score.

The biggest difference at 12 months was seen in questions 8, 9 and 10 which relate to running, jumping and hard physical labour, respectively. The mean score in question 8 in the operative group was 8.4 out of 10 as compared to 5.7 in the non-operative group, so a difference of 2.7 in favour of the operative group. For question 9, this was 8.3 in the operative group compared to 5.6, so a difference of 2.7 in favour of the operative group. For question 10, the mean score in the operative group was 9.1 as compared to 6.9, so a difference of 2.2 in favour of the operative group.

Complications within 12 months were assessed in all patients irrespective of whether the ATRS was filled in or not. In the operative group of 70 patients, 1 patient sustained a re-rupture (1.4%), with 1 patient sustaining a pulmonary embolism (1.4%). In the non-operative group of 103 patients, 3 patients sustained re-ruptures (2.9%) and 2 patients sustained a pulmonary embolism (1.9%). All re-ruptures were managed non-operatively using the VACOped boot and the non-operative management protocol starting at week 0. No patients were found to have sustained a sural nerve injury or infection post-operatively.

Discussion

This study demonstrates a significant improvement in outcomes at 12 months post-operatively when compared to the non-operative group. This was in every single question in the ATRS questionnaire, and the biggest improvement was seen in terms of running, jumping, and hard physical labour.

At 3 months and 6 months, no significant difference was seen in terms of outcomes. This was felt because at 3 months, patients are still weaning back into normal footwear, and at 6 months, the intensity of physiotherapy begins to increase along with patients feeling an increased confidence in the repair at this stage. The results favor operative intervention in patients aged ≥50 years in terms of 1-year outcomes.

The incidence of Achilles tendon ruptures is increasing with an ageing population that is increasingly active and demanding in terms of outcomes following injury. It has been shown in recent literature that with more middle-aged and elderly adults performing sports, such as pickleball and paddleball, the incidence of Achilles tendon ruptures is increasing and will continue to increase ¹¹ with an increasing number of patients being managed operatively in this age group of ≥50 years. ¹²

Very few studies have looked at outcomes in patients aged ≥50 years. Westin et al ¹³ performed a multi-centre review of 391 patients and found that at 12 months, elderly patients had a reduced heel-rise height but no difference in patient-reported outcomes. However, the average age in this study was just 40.4 years. Nestorson et al ¹⁴ performed a retrospective review of 25 patients aged 56 years or above, with 14 patients managed operatively and 11 managed non-operatively. They found that operative management overall resulted in reduced lower limb function and advocated for non-operative management in elderly patients. However, the numbers of patients in each group are relatively few, despite a 3-year average follow-up. Maffulli et al ¹⁵ performed percutaneous repair in 35 patients aged 65 years or above and found a mean ATRS of 69.4. However, the ATRS was performed between 49 and 110 months post-operatively.

As compared to the literature, the results in this study compare favourably in terms of ATRS score at 12 months with a larger number of patients aged 50 years of above who underwent percutaneous repair. In addition, the complication profile was also favourable. The study was performed by experienced foot and ankle consultants with dedicated physiotherapists to manage these patients over a 10-year period.

However, there are limitations of this study. Patients were not randomised and not stratified as per confounding variables. Therefore, patients who were more likely to benefit from operative intervention underwent an operation, making the study at risk of selection bias. This is supported by the CCI being higher in the non-operative group; therefore, the less comorbid patients underwent surgical intervention. In addition, the average age of the operative group was younger by 4.2 years. Furthermore, the ATRS percentage completion could be higher, especially in the non-operative group at 12 months (55.3%). Analyses were conducted on completers only, which may introduce nonresponse bias. However, because of time limitations in the clinic, postal reply overall resulted in a lower response. In addition, given the benefit of operative intervention at 12 months, those patients may have been more likely to respond to the ATRS questionnaire via postal service given their improvement post-operatively. This is why between 6 months and 12 months the percentage of responses in the operative group increases from 68.6% to 71.4% when naturally a lower response percentage is expected with time.

Conclusion

In a rapidly aging population who are increasingly more physically active, an acute Achilles tendon rupture can be managed operatively with favourable results in selected patients aged ≥50 years, in the hands of experienced surgeons with a dedicated physiotherapy department. The biggest improvement at 12 months is seen in terms of running, jumping and hard physical labour. Those patients who do not require these attributes can be managed non-operatively. Future work should include looking at predictive factors for those aged ≥50 years, such as what activity level pre-operatively helps determine acceptable post-operative outcomes balanced with the risks of surgery.

Supplemental Material

sj-pdf-1-fao-10.1177_24730114251413239 – Supplemental material for Percutaneous Repair in Patients Aged 50 Years and Older Is Associated With Good Outcomes in Acute Achilles Tendon Rupture

Supplemental material, sj-pdf-1-fao-10.1177_24730114251413239 for Percutaneous Repair in Patients Aged 50 Years and Older Is Associated With Good Outcomes in Acute Achilles Tendon Rupture by Salman Sadiq, Natalie Grocott, Abdelrahman Ibrahim, Amr Selim, Abdul-Rahman Gomaa, Matthew Philpott and Ashique Ali in Foot & Ankle Orthopaedics