January 2011

Achilles rupture redux

In the moment: Rehabilitation

Two studies back nonsurgical approach

By Jordana Bieze Foster

Nonoperatively treated Achilles tendon ruptures are no more vulnerable to re-rupture than those treated surgically as long as early mobilization is part of the protocol, according to two randomized studies that appear to contradict current evidence-based thinking.

Most meta-analyses of operative vs nonoperative management of Achilles rupture, including a Cochrane review from the University of Western Australia published in September, have concluded that re-rupture rates are significantly lower following surgery. However, few of the randomized studies included in those meta-analyses reflect the recent paradigm shift away from cast immobilization and toward bracing with a device that is removable to facilitate early mobilization. This early mobilization is increasingly being incorporated in both surgical and nonsurgical Achilles management protocols.

In a study published in the December issue of the Journal of Bone and Joint Surgery, researchers from the University of Western Ontario randomized 144 patients to operative or nonoperative treatment of acute Achilles tendon rupture, with all patients receiving an accelerated rehabilitation featuring early weightbearing and range of motion exercises. During a two-year follow up, re-rupture occurred in two patients (2.7%) in the surgical group and three patients (4.2%) in the nonsurgical group, a difference that was not statistically significant.

One month earlier, researchers from Kungsbacka, Sweden, reported the results of a similar trial in which 100 patients with acute Achilles rupture were randomized to operative or nonoperative treatment, with all patients receiving early mobilization. In the Swedish study, which was published in the American Journal of Sports Medicine, the re-rupture rate at 12 months was 12% in the nonsurgical group and 4% in the surgical group. This difference was not statistically significant, although the authors noted that it could be considered clinically important.

Both studies also reported more complications in the operative group than the nonoperative group, which is consistent with the previous literature. In the Western Ontario study, there were 13 complications in the surgical group compared to six in the nonsurgical group. The Swedish study reported complications in the surgical group only: two infections, two nerve-related complaints, and three cases of reduced ankle function due to scar contracture and pain.

The Western Ontario study found no clinically significant differences between groups with regard to strength, range of motion, calf circumference, or function as assessed with the Leppilahti scoring system. Similarly, in the Swedish study, Achilles tendon Total Rupture Score (ATRS) values did not differ significantly between groups at either six or 12 months. However, at six months, the surgical group outperformed the nonsurgical group with regard to concentric strength, hopping tests, heel-rise height, and heel-rise work. At 12 months, the only remaining between-group difference was for heel-rise work.

Those functional tests are helpful for predicting a patient’s ability to return to a normal level of activity following Achilles tendon surgery, according to a study from the Palo Alto Medical Foundation that was e-published by the Journal of Foot & Ankle Surgery on Nov. 22.

Investigators retrospectively analyzed 219 patients who underwent Achilles surgery during a 15 year period. Before being allowed to return to activity, patients were evaluated on their ability to perform five sets of 25 single-leg concentric heel raises, symmetry of calf circumference, and symmetry of ankle range of motion. Fourteen patients were unable to meet goals for all three criteria within the proposed time frame following surgery; return to activity was delayed in all such cases, which was a statistically significant finding.

The Palo Alto group also found that functional rehabilitation progress after Achilles tendon repair may be influenced by gender. Delayed return to activity was seen in 11 of 70 female patients (16%) compared to just two of 149 male patients (1.3%).

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