SLR - August 2020 - Amish K. Dudeja

Comparison of Tendon Lengthening With Traditional Versus Accelerated Rehabilitation After Achilles Tendon Repair

Reference: Okoroha KR, Ussef N, Jildeh TR, et al. Comparison of Tendon Lengthening With Traditional Versus Accelerated Rehabilitation After Achilles Tendon Repair: A Prospective Randomized Controlled Trial. Am J Sports Med. 2020;48(7):1720-1726

Scientific Literature Review

Reviewed By: Amish K. Dudeja, DPM
Residency Program: Beth Israel Deaconess Medical Center – Boston, MA

Podiatric Relevance: High variability is found between surgeons regarding postoperative management of surgical repaired Achilles tendons. Most surgeons have historically immobilized patients in plantar flexion for six weeks before allowing weight bearing out of concern for tendon lengthening. Elongation of the Achilles tendon has long been associated with inferior clinical outcomes and early reports of postoperative ankle motion versus rigid immobilization after acute Achilles tendon rupture repair demonstrated increased tendon elongation. More recently, studies have advocated for early weight bearing and have reported improved clinical outcomes. This study compares the difference in tendon lengthening after Achilles tendon repair with traditional versus accelerated rehabilitation protocols in 18 patients.

Methods: A level I prospective randomized controlled study was performed to include 18 patients undergoing primary Achilles tendon repair for mid-substance Achilles tendon ruptures between June 2017 and June 2019. Patients consented to have tantalum beads placed within the tendon and were randomized into either a traditional (weight bearing at six weeks) or accelerated (graduated weight bearing at two weeks) rehabilitation group. Postoperative tendon elongation as measured by radio stereometric beads served as the primary outcome measure of the study. Secondary outcomes included Achilles Tendon Total Rupture Score (ATRS) and Patient-Reported Outcomes Measurement Information System Pain Interference Short Form (PROMIS PI-SF) score. 

Results: All patients were found to have significant tendon lengthening after surgery, with an overall mean tendon lengthening of 15.9 millimeters. The differences in tendon lengthening between the traditional and accelerated rehabilitation group was not statistically significant (P = .33). The greatest amount of lengthening occurred between two and six weeks (8.8 millimeters, 56 percent of lengthening and the least amount of lengthening occurred between six and 12 weeks (2.0 millimeters and 6 percent of lengthening). Additionally, the repair site in each group was found to lengthen more than the intratendinous site. No complications such as re-rupture occurred in the study. There was also no significant difference in secondary outcomes among the two rehabilitation groups.

Conclusions: This study illustrated that all patients undergoing Achilles tendon repair will likely have a significant degree of lengthening. Few prior studies have directly compared the result of traditional versus accelerated post-operative protocols on tendon lengthening. The authors found no significant difference in not only tendon lengthening between the two groups, but that the re-rupture rate was also the same. The key finding of the study demonstrates that accelerated weight bearing protocols are safe after Achilles tendon repair and do not lead to an increased rate of re-rupture. Potential limitations of this study include variations in tendon repair technique and potential migration of the beads. Foot and ankle surgeons can use this data to suggest early mobilization protocols which can lead to patient satisfaction and low clinical risk.

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