SLR - April 2014 - Keith A.Canter
Reference: Nicklas Olsson, Karin Grävare Silbernagel, Bengt I. Eriksson, Mikael Sansone, Annelie Brorsson, Katarina Nilsson-Helander and Jón Karlsson. Stable Surgical Repair with Accelerated Rehabilitation Versus Nonsurgical Treatment for Acute Achilles Tendon Ruptures: A Randomized Controlled Study. Am J Sports Med 2013 41: 2867.
Scientific Literature Review
Reviewed By: Keith A.Canter, DPM
Residency Program: Mercy Hospital, Coon Rapids, MN
Podiatric Relevance: Early weight bearing and accelerated rehabilitation after Achilles tendon rupture have been shown to yield better outcomes in the current literature when compared to what was traditionally believed. Whether or not to surgically repair an acute Achilles tendon rupture continues to be a topic of debate within the field of podiatric surgery. This study hypothesized that following an acute Achilles tendon rupture, patients treated with a stable surgical repair and early accelerated tendon loading and range of motion training would have superior results compared with nonsurgical treatment with traditional rehabilitation.
Methods: This randomized controlled study included a total of 100 patients (86 men, 14 women; mean age, 40 years) with an acute total Achilles tendon rupture (closed midsubstance rupture) between April 2009 and October 2010. The patients were randomized to either surgical treatment, including an accelerated rehabilitation protocol, or nonsurgical treatment. Diagnosis was made based on medical history and clinical examination (palpable gap and positive Thompson test). Exclusion criteria included; rupture older than four days, prior Achilles tendon rupture, neuromuscular disease, diabetes, peripheral vascular disease, immunosuppressive treatment including systemic cortisone, skin infection or wound, and inability to attend rehabilitation or evaluations. The primary outcome was the Achilles tendon Total Rupture Score (ATRS). The patients were evaluated at three, six, and 12 months for symptoms, physical activity level, and function. Multiple clinical tests that have shown success in the past were used to evaluate function of the Achilles tendon including two jump tests (drop countermovement jump and hopping) and two strength tests. Muscular endurance was also evaluated by a single-leg standing heel rise test. These tests were used to answer the hypothesis that patients treated with stable surgical repair and early-accelerated tendon loading would have superior results compared with non-surgical treatment.
Results: There were no statistically significant differences between the two treatment groups at three, six and 12 months as evaluated by the ATRS. Both groups improved over time at the three, six and 12-month evaluation. There was a trend toward improved function in surgically treated patients; the results were significantly superior when assessed by the drop countermovement jump (95 percent CI, 0.03-0.15; P = .003) and hopping (95 percent CI, 0.01-0.33; P = .040). No re-ruptures occurred in the surgical group, while there were five in the nonsurgical group (P = .06). There were six superficial infections in the surgically treated group; however, these superficial infections had no bearing on the final outcome. Symptoms, reduced quality of life, and functional deficits still existed 12 months after injury on the injured side in both groups. There were no significant differences between the groups in terms of symptoms, physical activity level, or quality of life.
Conclusions: The authors concluded that stable surgical repair with accelerated tendon loading could be performed in all (n = 49) patients without re-ruptures and major soft tissue related complications. However, this treatment was not significantly superior to nonsurgical treatment in terms of functional results, physical activity, or quality of life. The authors also summarized that the results indicated that an Achilles tendon rupture does not simply affect the lower limb, but also affects the patient’s quality of life. The findings of this study reiterate the importance of treating each case individually because pre injury level will greatly vary from patient to patient. An active patient or athlete may benefit from stable surgical repair as shown by the limb symmetry index (LSI). The LSI values were consistently higher in the surgical group compared to the non-surgical group, especially with hopping and the drop countermovement jump at 12 months.