SLR - October 2020 - Amy G. Wilson
Early Mobilization Does Not Reduce the Risk of Deep Venous Thrombosis after Achilles Tendon Rupture: A Randomized Controlled Trial
Reference: Aufwerber S, Heijne A, Edman G, Grävare Silbernagel K, Ackermann PW. Early Mobilization Does Not Reduce the Risk of Deep Venous Thrombosis after Achilles Tendon Rupture: A Randomized Controlled Trial. Knee Surg Sports Traumatol Arthrosc. 2020;28(1):312-319.
Scientific Literature Review
Reviewed By: Amy G. Wilson, DPM
Residency Program: St. Mary’s Medical Center – San Francisco, CA
Podiatric Relevance: Achilles tendon rupture (ATR) is the sports-related injury with the highest risk of developing a deep venous thrombosis (DVT). Early functional mobilization (EFM) in the postoperative course, via means of weightbearing and ankle motion, has gained popularity when compared to a more immobilized course following ATR repair. Though lacking in evidence-based research, it has been speculated that the EFM protocol is associated with a decreased DVT incidence after ATR repair. The purpose of this study was to evaluate the efficacy of the EFM program in reducing incidence of DVT after ATR repair when compared to an immobilized postoperative protocol.
Methods: This was a randomized controlled trial for patients who underwent end-to-end surgical repair of acute ATRs. Postoperatively, patients were assigned to a ‘EFM’ or ‘control’ group. Neither group received postoperative thrombolytics. EFM participants were placed in an ankle-mobile orthosis and permitted to be WBAT with fixed plantarflexion capability (15-30 degrees) for the first two postoperative weeks with progression of plantarflexion (5-30 degrees) from week two through six. Control participants were placed in a NWB plantarflexed cast for the first two postoperative weeks with progression to WBAT in an ankle orthosis from week two through six. DVT screening via duplex ultrasound occurred at 2 and 6 weeks postoperatively. Patient-reported loading, pain, and step counts were documented for the first two postoperative weeks. Secondary outcomes included identifying DVT risk factors.
Results: A total of 142 patients (EFM n=95; Control n=47) completed 6 weeks of follow up. No significant difference in DVT incidence between treatment groups at the 2 or 6-week mark was observed. Thirty percent of all patients demonstrated a DVT at two weeks (29 percent of EFM; 31 percent of Control) and 34 percent at six weeks (37 percent of EFM; 29 percent of Control). During the first postoperative week, the EFM group reported low loading and greater pain vs. the control group (p = 0.001). Independent risk factors for DVT included low patient-reported loading ≤ 50 percent, BMI >26, and age.
Conclusions: Overall, the authors determined no significant difference in DVT incidence between EFM and conventional immobilization protocols after ATR repair. However, the high DVT incidence demonstrated by this study (37 percent) highlights the need to investigate more effective DVT prophylactic measures after ATR repair; whether this be through optimization of mobilization protocols or pharmacologic intervention. At minimum, the DVT incidence and associated risk factors reported should assist practitioners when educating patients inflicted by ATRs who are considering surgical repair.