SLR - December 2016 - Corey Bess

A Prospective Randomized Trial Comparing Surgical and Nonsurgical Treatments of Acute Achilles Tendon Ruptures

Reference: Lantto I, Heikkinen J, Flinkkila T, Ohtonen P, Siira P, Laine V, Leppilahti J. A Prospective Randomized Trial Comparing Surgical and Nonsurgical Treatments of Acute Achilles Tendon Ruptures. Am J Sports Med: 2016 Sep, 44(9): 2406–2414.
Scientific Literature Review

Reviewed By: Corey Bess, DPM
Residency Program: Montefiore Medical Center

Podiatric Relevance: Achilles tendon ruptures are the most common tendon rupture of the lower extremity. It is often misdiagnosed as an ankle sprain and may be missed in up to 25 percent of cases on initial presentation. Many systematic reviews and meta-analyses of RCTs for acute Achilles tendon ruptures in recent years suggest that nonsurgical and surgical treatments result in similar outcomes in terms of clinical scores and patient satisfaction. Previous long-term studies of acute Achilles tendon ruptures have shown that calf muscle strength recovers during the first year after the injury, with minimal improvement thereafter. Good calf muscle strength three to six months after an Achilles tendon rupture predicts better calf muscle endurance at one year. Early accelerated rehabilitation programs between three to six months after the injury may be the most important factor to minimizing strength deficits. The purpose of this study is to show if surgery allows for more aggressive rehabilitation and could result in better strength and earlier return to function compared with nonsurgical treatment.
Methods: The authors performed a prospective, open, parallel-group randomized trial to compare nonsurgical functional treatment to surgical treatment. Patients with complete acute Achilles tendon tear between the ages of 18 to 65 years. Exclusion criteria included a delay ≥1 week between the rupture and treatment, local corticosteroid injections around the Achilles tendon within six months before the rupture, prior surgery on the affected leg, previous Achilles rupture on contralateral limb, pregnancy, skin problems over the area, open Achilles rupture, diabetes mellitus or a persistent gap between the ruptured tendon in passive plantarflexion assessed by ultrasound. There were 60 patients in total, 32 in the surgical group and 28 in the nonsurgical. Nonsurgical treatment consisted of maximal plantarflexion and NWB for 1 week. Patients were then allowed FWB in AFO at 30 degrees PF for weeks two to three, 15 degrees PF weeks four to five and free movement from 0 to 30 degrees of PF for weeks six to seven. A home-based rehab program was started at seven weeks from injury. No formal physical therapy was done. The surgical treatment was performed within seven days of injury with simple end-to-end repair utilizing a Krackow technique. Postoperatively, the patients were NWB in full equinus cast for one week. After one week, they were advanced to FWB in an AFO in the exact fashion as the nonsurgical treatment protocol. Researchers looked at isokinetic calf muscle strength, and outcome measures were quantified with Lepplilahti Achilles tendon performance score and RAND 36-item Health Survey up to 18 months.

Results: Patients showed similar isokinetic calf strength at three months, but the surgical group had a 16 to 24 percent advantage at six months, and 10 to 18 percent high values at 18 months. The Leppilahti score was statistically similar in both treatment groups. The RAND 36-Item health survey demonstrated better results for the surgical group in terms of physical function. Complications included four reruptures in the nonsurgically treated group vs. one rerupture in the surgical group. One patient in the surgery group had a deep wound infection that was treated with surgical debridement and antibiotics.

Conclusions: The authors concluded that surgical and nonsurgical treatments of acute Achilles tendon ruptures have similar results in terms of the Achilles tendon performance score, but surgery restores calf muscle strength earlier over the entire range of motion of the ankle joint and may also result in better health-related quality of life in terms of physical functioning compared with nonsurgical treatment. They noted that their rerupture rates were higher for the nonsurgical group than many of those in recent literature, which was attributed to noncompliance with AFO.

From this study, the outcomes of surgical vs. nonsurgical treatment appear to have similar outcomes, with the surgical group having an advantage in calf strength and physical functioning. However, no formal physical therapy was done in either group, which could potentially close the gap in strength and functioning between groups as it has been shown to do in other studies.

The advantages and disadvantages to treating Achilles tendon ruptures are well studied and reported, and even with the recent reports of excellent outcomes in nonsurgically treated patients, this study shows there is still some benefit for surgery in physically active patients who desire to return to sport and may help them closer achieve their preinjury levels of activity.

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