Surgical vs. non-surgical treatment for Achilles tendon rupture

Lack of consensus exists for optimal treatment course
The standard course of treatment for acute Achilles tendon rupture continues to see constant modification, and an optimal treatment protocol is not fully accepted. Though some impressive meta-analyses appear to favor surgery by showing the re-rupture rate to be higher in patients treated non-surgically (12.6%) than surgically (3.5%), the risk of complications is far greater with a surgical intervention. One major development that has given power to the belief that non-surgical treatment is a viable option is the implementation of a functional brace that allows immediate mobilization. The use of these braces instead of cast immobilization for 6-8 weeks for non-surgical patients has led to a decrease in re-rupture rates, and has led to older studies being reexamined. To further evaluate treatment options for Achilles tendon rupture, an older study was reopened using a functional brace instead of immobilization to determine if surgery or rehab is superior.

Small study group followed closely for signs of distinction
Patients between 16-65 with unilateral Achilles rupture who were randomized and treated within 72 hours of the injury were sought, and a total of 97 patients comprised the study group. This group was then randomized, assigning 49 to surgery and 48 to rehab. Surgery was performed by orthopaedic surgeons familiar with the technique and patients were placed in a below-the-knee cast with the foot in a 30° equinus position following surgery. Non-surgical patients were treated immediately with the same cast. Patients in both groups wore the cast for two weeks, after which they wore an adjustable functional brace for the next six weeks, with follow-up examinations taking place at two, eight and 12 weeks, then at six and 12 months. Patients’ symptoms and physical activity levels were assessed using the Achilles tendon Total Rupture Score (ATRS) and a physical activity scale (PAS).

Outcomes of non-surgical treatment just as good as surgical
Overall, there were six (12%) re-ruptures in the rehab group and two (4%) in the surgery group, a minimal and insignificant difference. Patients in the surgery group had a mean ATRS of 72 points at the six-month follow-up and 88 at the 12-month, while the rehab group scored 71 at the six-month and 86 at the 12-month. PAS scores improved from 3.4 to 3.6 in respective follow-ups for the surgery group and from 3.3 to 3.7 for the rehab group. In each of these measures, there were no statistically significant differences between groups at either the six-month or 12-month follow-up evaluations, but both groups did show overall improvements. Based off these findings, it appears neither treatment group has been proven superior to the other, though early mobilization was beneficial for both groups. Since non-surgical treatment is less expensive and has fewer complications, it should be given proper consideration in evaluating treatment options.

-Summarized by Greg Gargiulo

-As reported in the August ’10 edition of The American Journal of Sports Medicine