Operative vs Nonoperative Treatment of Achilles Tendon Ruptures Using Early Functional Rehabilitation: Critical Analysis of Evidence

[Acute rupture of the Achilles tendon : Diagnostics, treatment and aftercare]

With up to 50 incidents per 100,000 inhabitants, Achilles tendon ruptures are among the most frequent tendon injuries encountered in orthopedics and trauma surgery. Apart from high-risk forms of sport, degenerative processes are primarily responsible for weakening and ultimately rupture. In addition to assessing the typical clinical signs with inability to perform powerful plantar flexion, the diagnostics include easy to earn examination techniques, such as the Thompson test and ultrasound as the imaging gold standard. Conservative and surgical treatment are available depending on the constitution, age and requirements of the patient. The latter option is divided into conventional open, minimally invasive or percutaneous procedures. Good to very good results can be expected regardless of the form of treatment, provided that early functional rehabilitation is carried out. The average rerupture rate is 5% and the return to sport rate is around 80%.

Achilles Tendon Rupture

There are many high-level studies comparing nonoperative treatment, open repair, and minimally invasive repair for Achilles tendon ruptures. This article summarizes the most up-to-date literature comparing these treatment options. The authors' preferred protocol for nonoperative treatment is discussed. Preferred techniques for open repair and chronic Achilles repair are discussed with reference to the literature.

Musculotendinous ruptures of the achilles tendon had greater heel-rise height index compared with mid-substance rupture with non-operative management: A retrospective cohort study

INTRODUCTION

Achilles tendon ruptures (ATRs) may occur at varying locations with ruptures at the mid-substance (MS) of the tendon most common, followed tears at the musculotendinous (MT) junction. There is scant literature about the outcome of MT ATR. This study compared the outcome of patients with a MT ATR with patients following a MS ATR.

METHODS

The diagnostic features and clinical outcome of 37 patients with a MT ATR were compared with a cohort of 19 patients with a MS ATR. Patients in both groups were managed non-operatively and received the same rehabilitation protocol with weight-bearing rehabilitation in protective functional brace.

RESULTS

From February 2009 to August 2023, 556 patients presented with an ATR. Of these, 37 (6.7 ​%) patients were diagnosed with a MT tear. At final follow-up, at 12 months following injury, the MT group reported an Achilles tendon total rupture score (ATRS) of mean (standard deviation (SD)) of 83.6 (3.5) (95 ​% confidence interval (CI) 81.8, 85.4) and median (inter-quartile range (IQR)) ATRS of 86 points (78-95.5) and the MS group mean (SD) of 80.3 (8.5) (95%CI) 76.1, 80.5) and median (IQR) of 87 points (59-95) (p ​= ​0.673). Functional evaluation, however, revealed statistically significant differences in mean (SD) heel-rise height index MT group 79 ​% (25) (95%CI 65.9, 92.1) and MS group 59 ​% (13) (95%CI 51.9, 67.1) (p ​= ​0.019). In the MT rupture group, there were considerably less complications than the MS rupture group.

CONCLUSIONS

When managed non-operatively, with only a 6 weeks period of brace protection, patients have little limitation although have some residual reduction of single heel-rise at the one-year following MT ATR.

LEVEL OF EVIDENCE

IV.

Reverse Fragility Index Comparing Rates of Rerupture After Open Achilles Tendon Repair Versus Early Functional Rehabilitation: A Systematic Review of Randomized Controlled Trials

BACKGROUND

Despite similar published rates of rerupture among patients treated with early functional rehabilitation and open repair for acute Achilles tendon rupture, uncertainty still exists regarding the optimal treatment modality. The reverse fragility index (RFI) is a statistical tool that provides an objective measure of the study's neutrality by determining the number of events that need to change for a nonsignificant result to be significant.

PURPOSE

The purpose was to utilize the RFI to appraise the strength of neutrality of randomized controlled trials (RCTs) comparing the rerupture rates of acute Achilles tendon ruptures treated with open repair versus early functional rehabilitation.

STUDY DESIGN

Systematic review; Level of evidence, 1.

METHODS

A systematic review was performed including all RCTs comparing the rerupture rates after operative repair and early functional rehabilitation for acute Achilles tendon ruptures. Studies were included that explicitly used early functional rehabilitation, defined as weightbearing and exercise-based interventions initiated within 2 weeks, as compared with open repair and reported a nonsignificant difference in rerupture rates. The RFI, with rerupture as the primary outcome, was calculated for each study (significance threshold, P < .05). The RFI quantifies a study's strength of neutrality and is defined as the minimum number of event reversals necessary to change a nonsignificant result to statistically significant.

RESULTS

Nine RCTs were included, with 713 patients and 46 reruptures. The median (interquartile range) rerupture rate was 7.69% (6.38%-9.64%) overall, 4.00% (2.33%-7.14%) in the operative group, and 10.00% (5.26%-12.20%) in the nonoperative group. The median RFI was 3, indicating that an outcome reversal of 3 patients was necessary to change the results from nonsignificant to statistically significant. The median number of patients lost to follow-up was 6 (3-7). Of 9 studies, 7 (77.8%) had a loss to follow-up greater than or equal to its RFI.

CONCLUSION

The statistical nonsignificance of studies reporting equivalent rerupture rates in the management of acute Achilles tendon ruptures with open repair versus nonoperative management with early functional rehabilitation can be reversed by changing the outcome status of only a few patients.

Outcomes of early versus late functional weight-bearing after the acute Achilles tendon rupture repair with minimally invasive surgery: a randomized controlled trial

INTRODUCTION

Optimal postoperative rehabilitation regimen for acute Achilles tendon rupture (AATR) remains unclear. It is important to evaluate whether early functional weight-bearing rehabilitation program after minimally invasive repair results in an earlier return to pre-injury activity but increases the risk of re-rupture.

MATERIALS AND METHODS

This was a prospective randomized controlled trial involving 68 AATR patients undergoing minimally invasive surgery. 34 patients were enrolled in early weight‑bearing mobilization accelerated rehabilitation group (AR group); 34 patients were enrolled in the traditional rehabilitation (TR) group. Outcomes measures included American Orthopaedic Foot and Ankle Society Score (AOFAS) score and Achilles Tendon Total Rupture Score (ATRS) score before surgery and 3, 6, and 12 months after surgery, incidence rate of Achilles tendon re-rupture and total complications, length of hospital stay, time return to work and sports.

RESULTS

There was no significant difference in preoperative basic data between the two groups. However, AOFAS score and ATRS score were better in AR group than TR group at 3 months postoperatively (92.4 ± 3.5 vs 88.3 ± 4.5, P < 0.01; 91.1 ± 4.4 vs 88.9 ± 3.4, P = 0.03, respectively), the mean length of hospital stay (4.7 ± 1.5 vs 7.6 ± 2.0 days, P < 0.01) and time return to work (4.5 ± 1.0 vs 7.5 ± 1.6 weeks, P < 0.01) were shorter in AR group than in TR group. No statistical significance was calculated in patient-reported outcomes during the rest of the follow-up time and complications.

CONCLUSION

Early accelerated rehabilitation with weight-bearing in patients with AATR after minimally invasive surgery results in better early functional outcomes and shows similar security and feasibility.

REGISTRATION NO

ChiCTR2100043398.