SLR - August 2022 - Gregory Hanks
Reference: Myhrvold SB, Brouwer EF, Andresen TKM, Rydevik K, Amundsen M, Grün W, Butt F, Valberg M, Ulstein S, Hoelsbrekken SE. Nonoperative or Surgical Treatment of Acute Achilles' Tendon Rupture. N Engl J Med. 2022 Apr 14;386(15):1409-1420.Level of Evidence: Level I, Randomized, Controlled Trial
Scientific Literature Review
Reviewed By: Gregory Hanks
Residency Program: DVA Puget Sound, Seattle, Washington
Podiatric Relevance: Achilles tendon rupture is one of the most common musculoskeletal injuries that occurs in the foot and ankle. The question of optimal management remains unsettled. Several studies have been performed on the topic but have previously been underpowered or had inconsistent treatment protocols. This randomized, controlled trial directly compares nonoperative, operative open-repair, and operative minimally invasive techniques over a one-year period to determine if there is a superior treatment modality.
Methods: This is a multicentered, randomized, controlled trial with 554 enrolled patients that compared nonoperative, operative open-repair, and operative minimally invasive surgery for acute Achilles tendon ruptures. Patients were required to be between the ages of 18 and 60 years old with no previous rupture. Patients were randomly assigned in a 1:1:1 ratio. All groups of patients underwent similar rehabilitation protocols which included two weeks of casting, six weeks of protected weightbearing in heel lifts, followed by 12 weeks of physical therapy. The primary outcome measures for this study were the Achilles’ Tendon Total Rupture Score (symptoms and physical limitations) at one year. Secondary outcomes included rerupture rate, nerve injury, SF-36 scores, adverse events, as well as measurements of physical performance.
Results: The nonoperative, operative open-repair and operative minimally invasive techniques showed no statistically significant difference in Achilles’ Tendon Total Rupture Score at 12 months (Non-operative -17.0 points, Open-repair -16.0 points, Minimally invasive -14.7, p=0.57). Secondary outcomes results varied. Rerupture rate was higher in nonoperatively managed patients. (Non-op 6.2 percent, Open-repair 0.6 percent, minimally invasive 0.6 percent). The rate of nerve injury was notably higher in the minimally invasive population. (Non-op 0.6 percent, Open-repair 2.8 percent, Minimally Invasive 5.2 percent). Overall serious adverse event, SF-36 scores, as well physical performance measures were not statistically significant among the three groups.
Conclusion: Treatment of Achilles’ tendon rupture with surgery, open-repair or minimally invasive surgery, as compared to non-operative treatment, was not associated with better outcomes at 12 months as noted by the Achilles’ Tendon Total Rupture Score. Differences found in the secondary data points noted an increased risk for rerupture among nonoperative patients and increased risk of nerve injury in those treated with minimally invasive surgery. This study adds additional prospective by taking account of the minimally invasive treatment of Achilles’ tendon ruptures and finds no significant advantage to the surgical modality. Unlike previously small studies with limited power and inconsistent treatment and rehabilitation protocols, this study provides a large, multicentered randomized controlled trial comparing the three treatment modalities.The study confirms what other previous studies have suggested, that the operative and non-operative treatment protocols have comparable long-term results and solidifies non-operative treatment as an equivalent treatment for Achilles’ tendon rupture.