More Support for Non-Operative Treatment of Achilles Tendon Rupture
A recently published study found no significant differences in functional outcome in operative versus non-operative treatment of patients with acute Achilles tendon rupture when surgeons used the same functional bracing protocol for both groups of patients.
Kenneth J. Mroczek, MD
Lim CS, Lees D,Gwynee-Jones DP. Functional outcome of acute achilles tendon rupture with and without operative treatment using identical functional bracing protocol. FAI 2017;38:1331-1336.
Lim et al report on 200 patients who were treated for an acute Achilles tendon rupture with an identical functional bracing protocol, regardless of whether surgical repair was performed, at their institution over a 10 year period.
Although indications for surgical repair depended on multiple factors including age, activity level, comorbidities, and surgeon preference, relative indications for surgery in this study were younger, high-demand patients or patients who presented more than 24 hours after injury. Relative contraindications to surgery were diabetes, tobacco use, steroid use, and peripheral vascular disease.
Both cohorts, operative and non-operative, underwent the identical bracing protocol:
- For the first 4 weeks, patients were non-weight-bearing in a cast placed in a relaxed equinus position.
- Patients then began partial to weight-bearing as tolerated in a CAM boot locked at 20° of equinus.
- Patients began physical therapy, and the ankle was progressively brought to neutral between the 6- to 8-week mark.
- From week 8 to week 12, patients began active and passive stretches, concentric and eccentric muscle strengthening, and proprioception exercises.
- At 3 months, patients were allowed to resume light jogging and they began single-limb heel raises.
- Running with further strength and distance activities began at 4 to 6 months after initial treatment.
Functional outcome was assessed using the Achilles tendon total rupture score (ATRS).
Of the 99 operative and 101 non-operative patients, 62 operative and 70 non-operative patients were available for follow-up at a minimum of 2 years. No significant differences were found between the groups. Furthermore, there were no significant differences between male and female patients or between older and younger (under age 40) patients.
The study by Lim et al supports the recent trend toward non-operative treatment of acute Achilles tendon ruptures. Although the study by Lim et al is limited by possible surgeon treatment selection bias, its findings are important: No difference in functional outcome between the 2 groups, between the genders, and between younger and older patients.
Surgeons must ensure that patients who choose non-operative treatment understand that their decision does not mean they will not receive any treatment. Proper functional bracing must be appropriately initiated in a timely manner to achieve an optimal outcome. As this study shows, non-operative treatment of acute Achilles tendon ruptures is becoming a more viable option for patients and clinicians.
Kenneth J. Mroczek, MD, is an Assistant Professor of Orthopaedic Surgery and Chief of the Division of Foot and Ankle Surgery, Department of Orthopaedic Surgery, NYU Langone Health – Hospital for Joint Diseases, New York, New York.
Dr. Mroczek has no disclosures relevant to this article.