SLR - November 2016 - Sam Gervais
Reference: Lantto I, Heikkinen J, Flinkkila T, Ohtonen P, Siira P, Laine V, Leppilahti J. A Prospective Randomized Trial Comparing Surgical and Nonsurgical Treatments of Acute Achilles Tendon Ruptures. Am J Sports Med. 2016 Sep;44(9):2406–14.Scientific Literature Review
Reviewed By: Sam Gervais, DPM
Residency Program: Regions Hospital/HealthPartners Institute for Education and Research – St. Paul, MN
Podiatric Relevance: The treatment of acute Achilles tendon ruptures is controversial as studies have demonstrated similar outcomes between surgical and nonsurgical management of these injuries in terms of rerupture rates, patient satisfaction and clinical scores. It has been shown that calf strength recovers during the first year following an Achilles tendon rupture with little improvement thereafter. Additionally, good calf strength three to six months following an Achilles tendon rupture predicts better calf muscle endurance and Achilles Tendon Total Rupture Score (ATRS) at one year post injury. Therefore, accelerated rehabilitation three to six months following an Achilles tendon rupture could minimize strength deficits. There have been no studies with identical rehabilitation protocols for nonoperative and operative treatments of acute Achilles tendon ruptures that have reported isokinetic strength data for the whole range of motion for the ankle joint. The purpose of this study is to compare clinical outcomes and calf strength recovery between conservatively managed and surgically repaired acute Achilles tendon ruptures with identical accelerated rehabilitation programs.
Methods: A prospective, open, parallel-groups randomized trial was designed to compare surgical and nonsurgical treatment. Patients age 18 to 65 presenting with complete rupture of the Achilles tendon were included in the study. Delay of greater than one week, local corticosteroid injection around the Achilles tendon within six months of rupture, previous surgery on the injured leg, open Achilles tendon ruptures, pregnancy, skin problems over the Achilles tendon, living outside of area, diabetes mellitus or a persistent gap between the ruptured tendon ends in passive plantar flexion as assessed by ultrasound were all exclusion criteria. Two investigators evaluated all eligible patients, and a diagnosis of a complete Achilles tendon rupture was made by the presence of a palpable dell and positive Thompson test on physical exam and later confirmed by radiologist evaluation of ultrasound exam. The radiologist also evaluated if tendon ends were able to be reapproximated by passive plantar flexion during ultrasound exam. Patients meeting eligibility criteria were then randomized into conservative or surgical treatments.
A total of 60 patients met the inclusion criteria and volunteered to participate in the study, with 32 patients randomized to the surgical group and 28 patients in the nonsurgical group. Nonsurgical treatment involved casting in maximal plantar flexion for the first week after which the patients were transitioned to a dynamic vacuum orthosis that allows customized plantar flexion. The ankle was placed in 30 degrees of plantar flexion for weeks two to three, 15 degrees of plantar flexion for weeks four and five and free movement from zero degrees to 30 degrees of plantar flexion for weeks six and seven. Full weightbearing was allowed after week one. A home-based rehabilitation program was initiated at week seven.
Surgical treatment was performed within the first week of surgery. The Achilles tendon was repaired using a Krackow technique with two #2 FiberWire and absorbable 2-0 suture circumferentially. A double Kessler locking look was also utilized for additional stability of the repair. The patients were placed in a below-knee plaster splint in a plantarflexed position to eliminate tension on the repair. The postop protocol was identical to the nonsurgical protocol.
The Leppilahti score at 18-month follow-up was the primary outcome measure, which includes both a subjective and objective component that includes pain, stiffness, muscle weakness, footwear restriction, range of motion and isokinetic calf muscle strength. Secondary outcomes included isokinetic calf muscle strength, measure at three, six and 18 months after injury, as well as the RAND-36, which is a health-related quality of life measurement. Complications were also recorded.
Results: The Leppilahti score at 18-month follow-up did not differ statistically between the groups; however, it was slightly higher for surgical patients, mean of 79.5, than nonsurgical patients, mean of 75.7. No difference was found between pain, stiffness, subjective calf muscle weakness, footwear restrictions, ankle joint range of motion or subjective outcome. Similar isokinetic calf muscle strength was observed at three months between the groups; however, surgically treated patients demonstrated statistically significant higher results in both peak torque and angle-specific peak torque at six- and 18-month follow-up. Neither group had full return of strength as compared to the contralateral extremity. Statistically higher results were also found in the surgically treated group in regards to the RAND-36 scores in the domains of physical functioning and bodily pain.
In regards to complications, there was a 14 percent rereupture rate in the nonsurgical group compared to three percent in the surgically treated group, although this was not statistically significant due to small study size. Patient age did not have any effect on rerupture rates. Of the surgical group, one patient developed a deep wound infection.
Conclusions: The results of this study supported previous studies reporting similar Achilles tendon performance scores between nonoperative and surgically treated acute Achilles tendon ruptures. The authors conclude that nonsurgical treatment with a functional rehabilitation protocol results in acceptable outcomes. However, this study demonstrated faster and better recovery of isokinetic calf muscle strength in surgically treated injuries. The RAND-36 scores in the domains of physical functioning and bodily pain had better results in the surgically treated patients suggesting a higher quality of life for patients treated surgically. Additionally, surgically treated acute Achilles ruptures resulted in a lower rerupture rate, although a larger study is required to determine if this finding was statistically significant. Finally, the authors state that optimal treatment should be made on a case-to-case basis, and they stress the importance of the rehabilitation phase to optimize return of calf strength.