SLR - May 2021 - Benjamin Kaplan
References: Xu XY, Gao S, Lv Y, Zhou F, Jiao C, Fan JX, Zhu TJ. Duration of Immobilization after Achilles Tendon Rupture Repair by Open Surgery: A Retrospective Cohort Study. J Orthop Surg Res. 2021 Mar 17;16(1):196.Level of Evidence: Level II, Retrospective cohort study
Scientific Literature Review
Reviewed By: Benjamin Kaplan, DPM
Residency Program: Our Lady of Lourdes Memorial Hospital – Binghamton, NY
Podiatric Relevance: It is inevitable for the foot and ankle specialist to be faced with a patient suffering from an Achilles tendon rupture. When these cases require surgical intervention, post-operative course can be as impactful as the decisions made in the operating theater. Various methods have been implemented in terms of duration of immobilization, often with an emphasis on reducing the risk of recurrence and decreasing time to activity. The goal of this study is to determine the optimal length of time a patient should be immobilized following open repair of the Achilles tendon while decreasing pain, complications, and time to rehabilitation.
Methods: In this retrospective cohort study, 266 patients from June 2015 to June 2019 underwent open repair of the Achilles tendon following complete tendon rupture, utilizing Krackow locking loop and modified Kessler suture technique. All procedures were performed by the same surgeon at one university hospital. Patients were divided according to duration of immobilization into four groups; A,B,C,D, having no period of immobilization, two, four, and six weeks of immobilization post operatively respectively. In each group all patients were instructed to perform exercises on their own once the immobilization brace was removed. A suggested rehabilitation protocol was provided for the patient to follow as they progressed. Follow-up was conducted at 2,4,6,8,10,12,14,16,24, and 48 weeks. Time to light sports activity, ankle ROM recovery, single-legged heel rise in addition to complications, VAS, AOFAS and ATR scores were evaluated postoperatively. Data points were analyzed using Kruskal-Wallis H test and Fisher’s exact test.
Results: The mean time to light sports activity for groups A-D was 18.7 ± 2.0, 18.3 ± 1.8, 19.8 ± 1.4, 20.4 ± 1.8 weeks respectively. Ankle ROM recovery was recorded at 6.6±2.2 weeks after surgery in group A, 6.5±1.7 weeks in group B, 8.6± 1.3 weeks in group C, and 10.3±1.1 weeks in group D. ROM recovery occurred significantly faster for groups A and B than for groups C and D. Single heel rise was significantly faster in groups A and B. There were 13 complications consisting of superficial infections, DVT, and re-rupture. There were four re-ruptures; Group A (2), B (1), D (1). Group B had significant improvement in AOFAS scores at four weeks compared to groups C and D and compared to all groups at six and eight weeks. All groups increased in scores by 14 weeks. Similar patterns were seen with ATR scores with all groups increasing scores with time, however group B having significant improvements earlier. VAS scores reached 0 in all groups by 12 weeks.
Conclusions: Following surgical repair of the Achilles tendon, a two-week period of immobilization allows for earlier rehabilitation and weightbearing. Patients undergoing two weeks of immobilization had faster times to light sports activity and higher patient satisfaction outcomes within a 16-week period without increasing the risk of complications. This study did not classify or state how tendon ruptures were diagnosed preoperatively. Some limitations include a possible sex bias as a majority of the patients were male and no patients received professional physical therapy.