Background: To date, studies directly comparing the rerupture rate in patients with an Achilles tendon rupture who are treated with surgical repair with the rate in patients treated nonoperatively have been inconclusive but the pooled relative risk of rerupture favored surgical repair. In most studies the ankle is immobilized for six to eight weeks. Published studies of animals and humans have shown a benefit of early functional stimulus to healing tendons. The purpose of this review was to consolidate 2 research articles (European, 2010) and one review article (USA, 2015) looking at the outcomes of patients with an acute Achilles tendon rupture treated with operative repair and accelerated functional rehabilitation with the outcomes of similar patients treated with accelerated functional rehabilitation alone.
European Article 1: Willits et al
A total of 144 patients (seventy-two treated operatively and seventy-two treated nonoperatively) were randomized. There were 118 males and twenty-six females, and the mean age (and standard deviation) was 40.4 ± 8.8 years. Rerupture occurred in two patients in the operative group and in three patients in the nonoperative group. There was no clinically important difference between groups with regard to strength, range of motion, or calf circumference. There were thirteen complications in the operative group and six in the nonoperative group, with the main difference being the greater number of soft-tissue-related complications in the operative group.
Conclusion: It appears, that the addition of early weight-bearing and mobilization may have resulted in a substantially reduced rate of rerupture (4.6%). This study supports accelerated functional rehabilitation and nonoperative treatment for acute Achilles tendon ruptures. All measured outcomes of nonoperative treatment were acceptable and were clinically similar to those of operative treatment. In addition, this study suggests that the application of a nonoperative protocol involving accelerated rehabilitation will avoid serious complications related to surgical management.
European Article 2: Nilsson-Helander et al
There were 6 (12%) re ruptures in the nonoperative group and 2 (4%) in the operative group, but this result was not significant statistically. At the 6-month evaluation, the operative group had better results compared with the nonoperative treated group in some of the muscle function tests; however, at the 12-month evaluation there were no differences between the 2 groups except for the heel-rise work test in favor of the operative group. At the 12-month follow-up, the level of function of the injured leg remained significantly lower than that of the uninjured leg in both groups.
Conclusion: Results of this study did not demonstrate any statistically significant difference between operative and nonoperative treatment. Furthermore, the study indicates that early mobilization is beneficial for patients with acute achilles tendon rupture, whether they are treated operative or nonoperative.
USA Article Wang et al
From 2007 to 2011 in total, 12,570 patients were treated for an acute Achilles tendon rupture. The ratio of operative to nonoperative treatment increased from 1.41 to 1.65. Males were more likely to undergo surgery than females. There were no significant differences in short-term rerupture rate for operative (2.1%) versus nonoperative (2.4%) treatment. The proportion of patients who received operative treatment for an acute Achilles tendon rupture increased slightly during the 5-year period, suggesting that surgeons in the United States have been slower to adopt nonoperative treatment than their European counterparts.
USA model has a stronger tendency to surgery, even though European data showing no significance in rerupture rates or physical outcome measures, but more complications and greater financial cost
In addition to rerupture rates, need to also take into consideration surgery specific complications; DVT, pulmonary embolism, deep and superficial infection, scar keloid, adhesion and irritations cf. non operative
Protected weight bearing needs to be around 6- 8 weeks. I test this around 4 weeks with Thomson squeeze test. If there is a responding plantarflexion, I start very gentle PF isometrics
At 12 months all outcome measures including rerupture & client satisfaction, between operative and non operative were non significant
Comparisons between injured and non-injured limbs in both groups, showed a 100% gain in dorsiflexion and 80% plantar flexion strength at 12 months. Willits et al study followed their groups for 2 years and found the results unchanged.
At Esperance Physiotherpy we are able to provide the braces, crutches and Accelerated Functional Rehabiltiation programs discussed in these research artciles, either for those receiving operative or non operative treatments.
Nilsson-Helander, K et al. Acute Achilles Tendon Rupture. A Randomized, Controlled Study Comparing Surgical and Nonsurgical Treatments Using Validated Outcome Measures. Am J Sports Med 2010 38: 2186.
Willits K et al. Operative versus Nonoperative Treatment of Acute Achilles Tendon Ruptures.A Multicenter Randomized Trial Using Accelerated Functional Rehabilitation. J Bone Joint Surg Am. 2010;92:2767-75.
Wang, D et al. Operative versus nonoperative treatment of acute Achilles tendon rupture: An analysis of 12,570 patients in a large healthcare database Foot and Ankle Surgery 2015. Article in press.