SLR - March 2011 - Latasha Walters
Reference: Kevin Willits, Annunziato Amendola, Dianne Bryant, Nicholas G., Mohtadi, J., Robert Giffin, Peter Fowler, Crystal O. Kean and Alexandra Kirkley, J Bone Joint Surg Am. 2010;92:2767-2775. published Oct 29, 2010; doi:10.2106/JBJS.I.01401
Scientific Literature Review
Reviewed by: Latasha Walters, DPM, PGY-3
Residency Program: Southern Arizona VA Healthcare System
Podiatric Relevance:
Achilles tendon rupture is the most common tendon injury in the adult population. Podiatric physicians consistently face this challenge within their current patient base. Therefore, operative vs. non-operative treatment of Achilles tendon rupture is an interesting and very useful clinical question. This is a level I study that states that immobilization and primary repair of the Achilles tendon could actually be detrimental to the patient leading to re-rupture of the tendon.
Methods:
The sample of 144 patients was gathered from 2 surgical centers using a randomized control trial method. The sample included 118 males and 26 females. Each patient suffered a complete Achilles tendon rupture evidenced by Thompson squeeze test, actual palpable gap, and loss plantar-flexion strength. The group was separated into 2 groups, non-operative and operative. The operative group was immediately primarily repaired using Krakow stitch with non-absorbable suture. All of the patients were then started at the 2 week mark after rupture on "acclerated functional rehabilitation." Accelerated functional rehabilitation for both groups included wearing a below the knee removable orthosis with 2cm heel lifts and 20% plantar-flexion and early range motion exercises. No patients were immobilized or made non-weightbearing. They were analyzed at 6, 12, and 24 months post injury.
Results:
The study found using Leppilahti scores (which measures functional outcome including patient’s reported pain and stiffness) ankle ROM, and calf circumference that there was little to no statistical significance in the outcomes between operative and non-operative rates of re-rupture with accelerated functional rehabilitation. There was a very small but notable increase in plantar-flexion strength in patients who underwent operative repair. Re-rupture occurred in 2 operative patients and 4 non-operative patients out of the entire sample of 72.
Conclusion:
This study provides another avenue of treatment for the compliant patient who is willing to undergo weeks of physiotherapy. These researchers also mention that there were some wound complications associated with primary repair that could have been averted if an operative route was avoided. For either group it would appear that accelerated functional rehabilitation should be implemented for Achilles tendon ruptures, and that weight-bearing aids recovery. This circumvents complications associated with immobilization, like deep venous thrombosis and muscle atrophy. It's necessary to know that the degree of injury was not described or classified. For example, using the Kuwada classification to illustrate how much damage or defect each patient suffered. It is also important to note that imaging modalities like MRI were not used to diagnose for study purposes.