SLR-March 2014-Anthony Cavallo
Reference: Olson, N., et al. Stable Surgical Repair with Accelerated Rehabilitation Versus Nonsurgical Treatment for Acute Achilles Tendon Ruptures. A Randomized Control Study. American Journal of Sports Medicine, 41(12): 2867-2876, 2013.
Scientific Literature Review
Reviewed by: Anthony J. Cavallo, DPM
Residency Program: Inova Fairfax Hospital Podiatric Residency Program
Podiatric Relevance: The optimal treatment of acute Achilles tendon ruptures is still a matter of debate. Early loading of the tendon has been demonstrated to be beneficial to recovery and reduce complications. Previous literature has focused on re-rupture rates and deep infections without focusing on functional outcomes. The primary aim of the study was to determine whether stable surgical repair with early tendon loading could improve patient-reported outcomes and function after an acute Achilles tendon rupture.
Methods: 100 patients (86 men, 14 women) with a mean age of 40 were randomized to surgical treatment, including an accelerated rehabilitation protocol, or non-surgical treatment following an acute Achilles tendon rupture. The primary outcome was the Achilles tendon Total Rupture Score (ATRS). The lower the value of the ATRS, the greater the limitations to physical activity and greater the symptoms. Patients were evaluated at 3,6, and 12 months for symptoms, level of physical activity, and function.
Results: The surgical group had a median ATRS of 44 (range, 11-86; mean, 43+/- 20) at the three month evaluation, a median ATRS of 75 (range, 0-99; mean, 70 +/- 20) at the six month evaluation, and a median ATRS of 89 (range, 0-100; mean, 82 +/- 20) at the 12 month evaluation. The non-surgical group had a median ATRS of 33 (range, 6-73; mean, 35 +/- 14) at the three month evaluation, a median ATRS of 73 (range, 33-97; mean, 70 +/- 19) at the six month evaluation, and a median ATRS of 90 (range, 2-100; mean, 80 +/- 23) at the 12 month evaluation. There was no statistically significant difference between the two groups at 3,6, and 12 months by the ATRS, with significant improvement of both groups over time. There was no significant difference between groups when evaluating symptoms, physical activity, or quality of life.
There was a trend towards improved function in the surgically treated patients. No re-ruptures occurred in the surgical group, with five occurring in the non-surgical group. There were six superficial infections in the surgical group that were determined to have no bearing on the final outcome.
Conclusions: Stable surgical repair with accelerated tendon loading could be performed in all (49) patients without re-ruptures or major soft tissue complications. However, surgical repair was not shown to be significantly superior to non-surgical treatment regarding functional results, physical activity, or quality of life.
Immediate weight bearing with an accelerated rehabilitation protocol following surgical repair or non-surgical management of an acute Achilles tendon rupture is an effective approach to treatment as evidenced by this study. In patients who elect non-surgical manage mentor are otherwise not ideal candidates, comparable functional results to surgical repair are not unrealistic. However, the increased risk of re-rupture with non-surgical repair remains apparent based on the results of this study.