Operative versus Nonoperative Treatment of Acute Achilles Tendon Ruptures
A Multicenter Randomized Trial Using Accelerated Functional Rehabilitation
1 WOLF Orthopaedic Biomechanics Lab (C.O.K.), Fowler Kennedy Sport Medicine Clinic (K.W., J.R.G., and P.F.), 3M Centre, The University of Western Ontario, London, ON N6A 3K7, Canada. E-mail address for K. Willits: kwillit@uwo.ca. E-mail address for J.R. Giffin: rgiffin@uwo.ca. E-mail address for C.O. Kean: ckean@unimelb.edu.au. E-mail address for P. Fowler: pfowler@uwo.ca
2 University of Iowa Sports Medicine, The University of Iowa Hospitals and Clinics, 200 Hawkins Drive, Iowa City, IA 52242. E-mail address: ned-amendola@uiowa.edu
3 Orthopaedic Division, Department of Surgery, Elborn College, Room 1438, The University of Western Ontario, London, ON N6G 1H1, Canada. E-mail address: dianne.bryant@uwo.ca
4 University of Calgary Sport Medicine Centre, 2500 University Drive N.W., Calgary, AB T2N 1N4, Canada. E-mail address: mohtadi@ucalgary.ca
5 Deceased
A commentary by Michael S. Aronow, MD, is available at www.jbjs.org/commentary and is linked to the online version of this article.
Investigation performed at the Fowler Kennedy Sport Medicine Clinic, London, Ontario, and the University of Calgary Sport Medicine Centre, Calgary, Alberta, Canada
Disclosure: In support of their research for or preparation of this work, one or more of the authors received, in any one year, outside funding or grants in excess of $10,000 from PhysiciansServices, Inc. (PSI) and Aircast, Inc. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity.
Background To date, studies directly comparing the rerupture rate in patients with an Achilles tendon rupture who are treated with surgical repair with the rate in patients treated nonoperatively have been inconclusive but the pooled relative risk of rerupture favored surgical repair. In all but one study, the limb was immobilized for six to eight weeks. Published studies of animals and humans have shown a benefit of early functional stimulus to healing tendons. The purpose of the present study was to compare the outcomes of patients with an acute Achilles tendon rupture treated with operative repair and accelerated functionalrehabilitation with the outcomes of similar patients treated with accelerated functional rehabilitation alone.
Methods Patients were randomized to operative or nonoperative treatment for acute Achilles tendon rupture. All patients underwent anaccelerated rehabilitation protocol that featured early weight-bearing and early range of motion. The primary outcome was the rerupturerate as demonstrated by a positive Thompson squeeze test, the presence of a palpable gap, and loss of plantar flexion strength.Secondary outcomes included isokinetic strength, the Leppilahti score, range of motion, and calf circumference measured at three, six, twelve, and twenty-four months after injury.
Results A total of 144 patients (seventy-two treated operatively and seventy-two treated nonoperatively) were randomized. There were118 males and twenty-six females, and the mean age (and standard deviation) was 40.4 ± 8.8 years. Rerupture occurred in two patients in the operative group and in three patients in the nonoperative group. There was no clinically important difference between groups with regard to strength, range of motion, calf circumference, or Leppilahti score. There were thirteen complications in the operative group and six in the nonoperative group, with the main difference being the greater number of soft-tissue-related complications in the operative group.
Conclusions This study supports accelerated functional rehabilitation and nonoperative treatment for acute Achilles tendon ruptures. Allmeasured outcomes of nonoperative treatment were acceptable and were clinically similar to those for operative treatment. In addition, this study suggests that the application of an accelerated-rehabilitation nonoperative protocol avoids serious complications related to surgical management.
For further information: http://www.ejbjs.org/cgi/content/abstract/92/17/2767?etoc
