SLR - February 2015 - Matthew Rementer
Reference: Jackson G, Sinclair VF, McLaughlin C, Barrie J. Outcomes of Functional Weight-bearing Rehabilitation of Achilles Tendon Ruptures. Orthopedics. 2013 Aug;36(8): e1053-9.Scientific Literature Review
Reviewed By: Matthew Rementer, DPM
Residency Program: Phoenixville Hospital
Podiatric Relevance: Achilles tendon ruptures are a very difficult pathologic process to treat. There is a long recovery period associated with this injury including historically a long non-weight-bearing time period. This article discusses the outcomes of functional weight-bearing rehabilitation of Achilles tendon ruptures in both surgical and non-surgical groups. They hypothesized that there would be no significant differences in rerupture rates and functional outcomes between both groups.
Methods: From May 2008 to December 2002, the authors treated 80 consecutive patients for acute Achilles tendon rupture in this prospective study. The patients were provided information about both non-operative and operative treatments including rerupture rates and wound complications and were allowed to choose their treatment. All patients were diagnosed based on history and clinical examination including Thompson test and tendon palpation for a gap. All patients were placed in a prefrabricated ankle orthosis, which allows for different ankle positions throughout treatment for postoperative rehabilitation and non-operative care. In surgical patients, a standard Kessler technique was used. Patients in both groups were permitted to bear full weight as pain allowed at 30° plantarflexion for 1-2 weeks followed by 15° plantarflexion for 1-2 weeks, plantigrade for 1-2 weeks and finally 10° dorsiflexion for 1-2 weeks. Protected active ROM was started when the patient reached 15° or less of plantarflexion. The VISA-A and ATRS questionnaires were used to evaluate functional outcomes and reruptures and complications were recorded from office notes.
Results: Of the 80 patients, 51 chose non-operative treatment and 29 chose operative treatment. Patients in the non-operative group were a decade older than those in the operative group. The rerupture rate for the non-operative group was 4 percent (n=2) and 3 percent (n=1) for the operative group. The overall wound problems in the operative group was 10.3 percent (n=3) with one keloid scar and 2 wound infections treated by oral antibiotics. The overall questionnaire follow-up rate was 83 percent (n=66) with 14 patients lost to follow-up because they could not be contacted. Of the patients that participated in sports before the injury, 75 percent of the non-operative group returned to some level of sport while 86 percent of the operative group returned to some level of sport after treatment. All patients that were working before injury returned to work. The non-operative group scored a median of 84 points and 66 points on the ATRS and VISA-A respectively, while the operative group scored a median of 94 points and 91 points respectively.
Conclusions: The study was able to show that functional rehabilitation with early mobilization is a satisfactory approach for the management of Achilles tendon ruptures in terms of patient-reported function and rerupture rates. When looking at both groups, it is difficult to compare the two because the non-operative group was older by a decade and more sedentary before and after the surgery. Because of this, it is difficult to draw any conclusion about non-operative versus operative treatments from this study. This study does show a much lower rerupture rate in the non-operative group compared to previous studies. I believe that the strongest conclusion that you can take away from this study is that it is safe for patients to begin functional rehabilitation with early mobilization as soon as possible with Achilles tendon ruptures.