SLR - June 2022 - Navita Khatri, DPM
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. doi: 10.1056/NEJMoa2108447. PMID: 35417636.Level of Evidence: Level II, Randomized controlled trial
Scientific Literature Review
Reviewed By: Navita Khatri, DPM
Residency Program: Emory University School of Medicine, Emory Decatur Hospital – Decatur, GA
Podiatric Relevance: Within the field, there is debate as to whether or not to treat acute Achilles’ tendon tears operatively or non-operatively. Randomized, controlled trials comparing non-operative treatment with open repair have shown similar reported patient outcomes. There are fewer studies comparing non-operative treatment with traditional open repair and minimally invasive repair. The authors, in this study, conducted a multicenter, randomized trial to compare these three options.
Methods: The data was gathered from four centers in Norway, 526 patients were included in the final analysis. The primary outcome was the change from baseline in the Achilles’ tendon Total Rupture Score at 12 months. Secondary outcomes included the change from baseline in the Achilles’ tendon Total Rupture Score at the 3 and 6 month follow-ups, the change from baseline in the subscore for physical functioning, the physical component summary and the mental component summary on the 36-Item Short Form Health Survey at the 6 and 12 month follow-ups, physical performance at the 6 and 12 month follow-up and the incidence of tendon re-rupture at the 12 month follow-up. All the participants followed a standardized rehabilitation protocol.
Results: The change in the Achilles’ tendon Total Rupture Score from baseline to the 12-month follow-up was −17.0 points in the nonoperative group, −16.0 points in the open-repair group, and −14.7 points in the minimally invasive surgery group. Pairwise comparisons showed no difference between the groups. Likewise, there were no a differences among the groups in the changes in the ATRS at 3 months and 6 months or in the SF-36 physical functioning score or in the physical or mental component summaries at the 6 and 12 month follow ups. There were no differences among the groups in physical performance at the 6 and 12 month follow ups. There were 11 re-ruptures in the nonoperative group , one in the open-repair group, and 1 in the minimally invasive surgery group. The risk of re-rupture was 5.6 percent higher in the nonoperative group than in the two surgical groups. The risk of re-rupture was similar in the two surgical groups.
Conclusions: The authors’ concluded that surgery, either open or minimally invasive, was not associated with better outcomes than non-operative treatment at 12 months. However, it should be emphasized that the incidence of re-rupture is higher in the non-operative group. In my opinion, when choosing between surgery or non-operative treatment, it is important to look at the patient in whole. I would consider the patient’s activity level and co-morbidities when making this decision. If the patient is over-all healthy, active, I would lean towards operative treatment because of the high rate of re-rupture in the non-operative group. I would also consider the size of the defect. Also, when presenting the two options, the patient should be aware that the incidence of re-rupture is higher with the non-operative option.