Surgery Preferred Over Nonoperative Care for Achilles Tendon Rupture
The results of this study may help doctors and patients decide how to treat an acute rupture of the Achilles tendon. Previous studies support surgical repair over nonoperative treatment for this injury. This study confirms those findings and offers a comparison between the two treatment choices.

The main advantage of surgery compared with nonoperative care to repair the torn Achilles tendon is a lower rerupture rate. But the rates of infection, scarring, and nerve injury is much higher for surgical repair.

There is some suggestion that the complication rate after surgical repair of a ruptured Achilles tendon will continue to decline over the next few years with improved surgical technique. Surgeons can use minimally invasive (MI) methods. This allows for much smaller incisions and less disruption of the intact soft tissues.

After surgery, the patient can wear a special brace called functional bracing. The brace allows the individual to walk, exercise, and train for sports. Recovery is faster and return to work and sports occurs sooner. The risk of rerupture and other complications is low with bracing.

Nonoperative care is usually by casting or splinting to immobilize the leg. The foot is held in a position of slight plantar flexion (toes pointing down). This takes the pressure off the healing tendon. There is no risk of nerve injury as there would be with surgery. But recovery is delayed due to weakness of the injured calf muscle.

The authors of this study compare these two types of treatments. Patients with an acute Achilles tendon rupture treated within 72 hours were randomly placed in one of two groups.

Most injuries occurred in adults between the ages of 30 and 40. The injury happened while playing sports such as tennis, squash, and volleyball.

The first group had minimally invasive surgery to stitch the torn tendon back in place. A small incision (less than two inches long) was made. After surgery, a cast was applied and worn for one week. This was followed by six weeks of tape bandaging to protect the healing tendon. The foot was placed in slight plantar flexion using a heel raise. The height of the heel was slowly lowered over a period of several weeks until it was removed completely.

Patients in the nonoperative group were placed in a slightly plantar flexed cast for a week. This was followed by a period of time wearing a functional bracing system. The brace was made of lightweight plastic with a vacuum cushion inside. The sole was removable to allow for adjusting the amount of plantar flexion. The brace was to be worn continuously without taking it off between medical appointments. It was devised in such a way that the researchers would know if the patient took it off when he or she wasn't supposed to remove it.

In both groups, full weight-bearing was allowed on flat surfaces. Crutches could be used at first but these were not needed after the first week.

Results were measured using complications (other than reruptures). The number of reruptures were recorded but not expected to be different between the two groups. Range-of-motion, strength, and pain were measured. Satisfaction with treatment, return to work, and participation in sports were additional results measured. Patients were followed for a full year.

As it turned out, there were more reruptures in the nonoperative group (15 per cent) compared to the surgical group (five per cent). The major complications were skin-related (infections, sores, blisters). Most of the skin problems occurred as a result of the brace (nonoperative care) or tape bandaging (used after surgery).

Early on after the treatment, patients in the surgical group were less satisfied and in more pain than the nonoperative group. But as time went by, this reversed. At three and 12 months, the opposite was true. The nonoperative group had more pain and was less satisfied than the surgical group.

Time off work was significantly longer for the nonoperative group. But more patients in the nonoperative group were able to return to their former levels of sport within one year compared to the surgically treated patients. Further evaluation revealed other reasons (job or family) for the difference between these two statistics.

In summary, when using complications after treatment as a measure of results, surgical management of acute Achilles tendon ruptures was favored over nonoperative care. Problems with skin breakdown using the brace suggest the need to look for ways to improve the bracing system.
Roderick Metz, MD, et al. Acute Achilles Tendon Rupture. In The American Journal of Sports Medicine. September 2008. Vol. 36. No. 9. Pp. 1688-1694.