Conservative Management of Achilles Tendon Wounds: Results of a Retrospective Study

Abstract

Achilles tendon wounds are therapeutically challenging. The tendon`s functional importance, the paucity of soft tissue surrounding the ankle, and common patient comorbidities often limit surgical reconstructive procedure options.

Depending on wound depth and overall patient health, secondary intention healing of these wounds can take many months. At the authors’ wound care center, patients who are referred with recalcitrant, deep Achilles tendon wounds and who are able to visit the center two to three times per week are offered a protocol of topical hyperbaric oxygen (THBO) followed by low-level laser therapy (LLLT) and moisture-retentive dressings. A retrospective study was conducted to evaluate the outcomes of patients who received treatment for a deep Achilles tendon wound during the years 2004 through 2008. Patients who were seen but did not obtain care at the center were contacted via telephone. Of the 80 patients seen, 15 were referred for amputation, 52 obtained treatment elsewhere, and 13 received the THBO/LLLT protocol. Patient median age was 73 years (range 52–90 years) and most (85%) had diabetes mellitus.

  Average wound size was 90 cm2 (range 6.25–300 cm2) with an average duration of 11.7 months (range 2–60 months) before treatment. Complete re-epithelialization was achieved in 10 patients (77%) following a mean treatment time of 19 ± 10 weeks (range 5–42 weeks). Of those, seven remained ambulatory and ulcer-free at mean follow-up of 3.3 ± 1.8 years. Eight of the 52 patients (15%) who were not treated in the authors’ center reported their ulcer was healed and 15 (29%) underwent amputation. Considering the severity of these wounds, the observed treatment outcomes are encouraging and may present a reasonable alternative for some patients with Achilles tendon wounds. Research is needed to clarify the role of these modalities in the conservative treatment of patients with Achilles tendon ulceration.

Potential Conflicts of Interest: none disclosed

  Lower extremity wounds impact patient quality of life and represent an economic burden on healthcare resources. These chronic wounds can be due to a myriad of diseases but the principal causes are chronic venous insufficiency, peripheral arterial disease (PAD), and diabetes.¹

  Ulceration around the Achilles tendon carries an extra challenge due to the functional importance of the tendon and the paucity of soft tissue surrounding the ankle. Furthermore, tendinopathy with structural abnormalities of the Achilles tendon has been demonstrated in patients with diabetes, ^2,3 possibly further perturbing tendon healing and recovery in this population.

  Over the years, ulceration over the Achilles tendon typically has been treated with local or free flaps.⁴ These surgical reconstructive procedures may be limited by the need for healthy recipient vessels at the ankle and the patient’s ability to withstand prolonged surgery (4 to 8 hours). These requirements are often difficult to meet, especially in patients with uncontrolled diabetes mellitus with advanced micro- and macro vascular disease. Clinicians are reluctant to use skin grafts because they may tether the Achilles tendon and/or be too fragile to withstand normal daily wear and tear^4,5; therefore, ulcers over the Achilles tendon often are left to heal by secondary intention.

  In addition to surgery and/or standard moist wound care, adjunctive therapies such as topical hyperbaric oxygen (THBO) therapy and low-level laser therapy (LLLT) are available to help manage refractory wounds.

Low-Level Laser Therapy

  In vitro studies^6,7 conducted by the authors and others have shown that LLLT enhances cell proliferation in keratinocytes compared to sham irradiation. In animal models, ^8,9 LLLT was found to enhance recovery of ruptured tendons when compared to no laser therapy. Using a rabbit model, Elwakil⁸ transected and immediately repaired 30 unilateral Achilles tendons — 15 received He–Ne laser (632.8 nm) photostimulation treatment (wave mode 1J/cm²) while 15 served as the untreated control group. After 2 weeks, wounds in the treatment group showed well-organized fibroproliferative changes with properly aligned collagen bands and a less marked inflammatory tissue response than in the control group where the collagen bands were poorly aligned and a marked inflammatory and granulomatous reaction was observed. Results of a literature review¹⁰ suggest that application of LLLT using recommended dosages can be effective when treating tendinopathy in humans. In addition, LLLT has been used in the treatment of acute and chronic wounds. Kleinman et al11 applied LLLT to 42 patients with chronic venous ulcers; complete wound closure was achieved in 36 patients (86%). During mean of 19.29-month follow-up (range 3–32 months) of 35 patients, two experienced a recurrence. Saltmarche¹² described use of LLLT in 21 wounds in nursing home residents. After 9 weeks, nine wounds had closed (four had been chronic wounds), seven (four chronic) showed some improvement, and five (three chronic) remained unchanged. Several reviews have been published on the topic, but despite LLLT’s increasing popularity as a clinical tool, well-designed clinical trials in this field are still needed.^13-15

Topical Hyperbaric Oxygen

  Topical oxygen therapy provides an inexpensive mode of delivering oxygen to the wounds without risk of multiorgan oxygen toxicity. Although topical oxygen is not likely to diffuse into deeper tissues, it has the advantageous potential to oxygenate superficial areas of the wound not supported by intact vasculature. ^16-18

  Topical oxygen is thought to promote angiogenesis by inducing vascular endothelial growth factor (VEGF) expression. Fries et al19 used topical oxygen on open dermal wounds in pigs. Each of the four pigs had 10 wounds created on the back, half exposed to topical oxygen and half not treated. Topical oxygen accelerated wound closure as measured by histology, increased keratin-14, VEGF expression, and tissue partial oxygen pressure (pO₂).

  Gordillo et al²⁰ exposed 25 wounds to topical oxygen and obtained serial wound tissue biopsies over the course of 12 weeks of therapy, or until closure, whichever came first. For each patient who responded to topical oxygen — ie, their wounds got smaller — there was a substantial and cumulative increase in VEGF expression in the wound tissue over time. The overall response rate to topical oxygen was 83%.

Purpose

  For many years, the authors have used a combination of LLLT and THBO to treat Achilles tendon injury in patients who were referred to their center but did not want to undergo or were not good candidates for reconstructive surgery. The purpose of this retrospective study was to evaluate the outcomes of all patients in the Bikur Cholim Hospital Wound Care Center database who received treatment for a deep Achilles tendon wound during the years 2004 through 2008.

Treatment Protocol

  General practitioners, orthopedists, dermatologists, and vascular surgeons refer patients with chronic ulcers to the wound center. All patients initially undergo, or have already undergone, a vascular evaluation and assessment of the affected limb. When required, patients are provided revascularization either by percutaneous transluminal angioplasty or by surgical bypass. If neither is feasible, patients are treated with IV prostacyclin analogue (Iloprost, Bayer Schering Pharma AG, Germany), according to the manufacturer’s instructions for use; antiplatelet treatment also is administered. Bacterial cultures are obtained during the initial evaluation and as needed thereafter. A broad-spectrum antibiotic is prescribed until wound culture and sensitivity results are available. Several topical treatment modalities are available, tailored to the specific wounds. Superficial wounds are managed solely with wound dressings; Promogram wound dressing (Systagenix Wound Management, Quincy, MA), Silvercell (Systagenix Wound Management, Quincy, MA), Polymem (Ferris PolyMem®, Ferris Mfg. Corp., Burr Ridge, IL), or Granugel (ConvaTec, Skillman, NJ) are generally used. Surgical debridement and antibiotics are provided as necessary. Nonresponding superficial wounds are treated with LLLT as well.

  LLLT is applied using a pulse scanner beam laser type ML 300 (Medi-Electronics, Germany) with a combination of Helium-Neon (632.8 nm, 20mW, 10K Hz) and Gal-Ars infrared lasers (785 nm, 80mW, 10K Hz) on an 100-cm² area with average energy density 0.9 J/cm² for 15 minutes. This is followed by application of Bio-Photon, HPT 3D diode laser (Medical Electronics, Germany), containing 64 laser diodes 785 nm (infrared) and 64 laser diodes 560 nm (blue), both calibrated to 6 mW effective per diode, for 512 seconds per session on a 400-cm² area with an energy density of 0.95 J/cm².

  Deeper and more complicated wounds receive THBO and LLLT consecutively. THBO is delivered by sealing the affected limb in a chamber (TOPOX, Topical Hyperbaric Oxygen Chamber, NJ) in which the pressure cycles every 12 seconds between 0 mm Hg and 30 mm Hg (1.0 and 1.04 atm absolute pressure) for 90 minutes at each session, as recommended.²⁰ THBO is not used in patients with severely compromised circulation (ankle brachial index [ABI] <0.4). THBO is used first followed by LLLT because a review of the literature has shown the oxygen provided by THBO to the compromised tissue stimulates key processes associated with wound healing,¹⁷ thereby priming the injured tissue for the biological effects of LLLT. Because THBO is expensive and not generally reimbursed by the HMOs in Israel and it requires frequent wound center visits, its use is limited to patients with deep and chronic wounds only.

  All treatment protocols were approved by the hospital’s ethical and clinical committees.

  Patients generally receive two to three treatment sessions a week. Dressings were not changed between treatments. A holistic approach to patient care is maintained throughout ulcer treatment. Diabetes control is emphasized and drug adjustments are made as necessary for patients with congestive heart failure and other concomitant conditions. Drug and diet adherence are assessed at every center visit. Pain is treated with analgesics and occasionally narcotics if necessary. Neuropathic pain is managed with gabapentin or pregabalin.

Methods

  The files of all patients with foot ulcers referred for consultation to the authors’ wound care center between the years 2004 and 2008 were retrieved. Information extracted included patient age, dates of initiation/cessation of therapy, number of sessions, presence of peripheral arterial disease and its treatment, presence of comorbidities including diabetes mellitus (and HbA1C where applicable), venous insufficiency, renal failure, cultures and subsequent treatments received, length of follow-up, and long-term outcome. These data were gathered on all patients who had ulcers involving the Achilles tendon and were entered into an Excel spreadsheet. Patients who had been evaluated for but did not return for treatment at the center were contacted via telephone to inquire about the status of their wound. Descriptive statistics were used for all outcome variables.

Results

  Between 2004 and 2008, 461 patients with foot ulcers were referred for consultation. Of those, 80 (17%) had ulcers involving the Achilles tendon; 15 of these patients (19%) were not considered good candidates for treatment and subsequently underwent amputation. Of the remaining 65 patients, 52 (65%) decided to obtain ulcer treatment elsewhere for financial/other reasons and 13 (16%) — seven men and six women, mean age 73 ± 11.5 (range 52–90) years — were treated at the authors’ center (see Table 1). Nine ulcers were secondary to diabetes mellitus, eight to PAD, four to venous insufficiency, and two to pressure. Of the patients with PAD, six underwent revascularization procedures, one underwent chemical sympathectomy, and one did not require intervention (see Table 2). All patients had multiple comorbidities, including ischemic heart disease (eight, 62%), hypertension (11, 85%), chronic obstructive pulmonary disease (COPD)/asthma (five, 38%), and chronic renal failure (five, 38%); one was receiving hemodialysis treatment and another had undergone renal transplantation.

  The average ulcer size was 90 cm² (range 6.25–300 cm²) and ulcers had existed an average of 11.7 months (range 2–60 months) before treatment at the wound center. The mean duration of treatment at the center was 19 ± 10 weeks (range 5–42 weeks). Six patients (46%) initially were hospitalized and their condition stabilized in conjunction with initiation of the wound care protocol. Culture results showed a high prevalence of methicillin-resistant Staphylococcus aureus (MRSA) — nine out of 13 (69%)— and Gram-negative bacteria — eight out of 13 (61.5%) (see Table 3). Three patients did not receive THBO due to severely compromised circulation and/or pain during treatment.

  Ten patients (77%) had complete re-epithelialization of the wound (see Figures 1 and 2) and two (15%) underwent amputation due to wound progression and intractable infection. Patient 12’s wound progression was attributed to failed revascularization. Patient 10 had been referred to the center after a prolonged hospitalization that included mechanical ventilation, recurrent sepsis, and concurrent pressure ulcers on his legs. He did not overcome his catabolic state throughout the treatment period. Two patients who showed reduction in ulcer size were unable to continue treatment because they were unable to travel to the center twice a week per protocol. Patient 11’s wound remains unhealed 2 years after cessation of treatment; he still had chronic ulcers. Patient 13’s wound had partially improved; her ulcer was treated conservatively in a facility closer to her home and healing was reported approximately 3 months after the end of the study.

  Of the 10 patients who had complete recovery, seven were ambulatory without ulcer recurrence at a mean follow-up time of 3.3 ± 1.8 years. Of the 52 patients who obtained care elsewhere, 11 could not be contacted and of the remaining patients, only eight healed (see Table 4).

Discussion

  The recovery rates reported in this study are similar to those reported by others using various combinations of surgical techniques and topical oxygen. Kalliainen et al²¹ conducted a retrospective analysis of wound outcomes among 32 patients (58 wounds) that did not heal by traditional means; 10 patients had diabetes mellitus. Following treatment with THBO for an average of 11 weeks, 65.5% of wounds healed and an additional 6.89% healed following surgical closure.

  Attinger et al⁴ described outcomes of 49 patients with Achilles tendon wounds; 16 had diabetes mellitus. All initially were surgically debrided and skin grafted or reconstructed with a local flap. In nearly half of the wounds, additional treatments were required — eight received THBO and 10 received systemic hyperbaric oxygen. No data were provided on the outcome of the patients treated with THBO. The overall proportion of wounds healed using an undifferentiated combination of various approaches including topical oxygen was 83% in an average of 13.3 weeks.

  Landau et al²² conducted a retrospective case study involving 374 patients with diabetic foot ulcers (218) Wagner grades I through IV and chronic venous ulcers (156) with a combination of THBO and LLLT; 68% of all patients healed.

  In the current study, the proportion of patients with diabetes mellitus was very high (69%), possibly because these patients are less likely to be good candidates for surgical closure than persons without diabetes mellitus. Although the proportion of wounds healed in this study was comparable (77%), selection bias may explain the prolonged mean time to healing (19 ± 10 weeks) when compared to other reported case series. It is conceivable that the favorable outcomes, despite the severity of the wounds and patient comorbidities, are the result of the synergism of both interventions.

  The proportion of patients healed among those who were eligible for but did not receive treatment at the authors’ center was much lower. Although no initial treatment selection bias existed between these two groups, patients treated at the authors’ center may represent a cohort with higher socioeconomic status because the treatments are costly and require frequent clinic visits. To the best of the authors’ knowledge, no other centers in Israel offer this treatment protocol and no other outcomes data are available. Because evidence on wound care interventions for these wounds is scant,²³ additional studies are needed to clarify the role of these modalities in the conservative treatment of patients with Achilles tendon ulceration.

Conclusion

  Topical hyperbaric oxygenation in conjuction with LLLT was found to be a reasonable alternative for patients who did not undergo surgery for Achilles tendon wounds. Further research is needed to corroborate these findings and to identify patients who may benefit from these combined modalities.

Dr. Kleinman is Head of the Diabetes and Wound Care Center and former Head of the Department of Medicine, Bikur Cholim Hospital, Jerusalem, Israel. Dr. Cahn is a Fellow in Endocrinology, The Department of Endocrinology and Metabolism, Hadassah-Hebrew University Hospital, Kiryat Hadassah, Jerusalem, Israel. Please address correspondence to: Avivit Cahn, MD, University Hospital, Kiryat Hadassah, POB 12000, Jerusalem 91120, Israel; email: avivit@hadassah.org.il.

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