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Achilles Tendon Ruptures: Is Surgical Repair More Effective Than Conservative Care?
Yes. In a thorough review of the literature on Achilles tendon ruptures, this author contends that surgical repair is superior to non-operative treatment in a multitude of populations, especially when factoring in new advances in technique and an emphasis on early mobilization.
By Priya Parthasarathy, DPM, DABPM
Optimal management of Achilles tendon rupture continues to be a point of debate in the foot and ankle community. The incidence of Achilles tendon injury and ruptures appears to be on the rise.1 The Achilles tendon is the strongest tendon in the body and pulls with tremendous force. Therefore, injuries can be violent even with low energy causation. Most current treatment algorithms agree on surgical repair for non-obese healthy active individuals younger than 30 to 35 years of age with a rupture gap greater than two centimeters. However, there appears to be a less clear-cut “gray zone” with older, physically fit adults as well as the younger but inactive population. Lately, the research appears to shifting toward conservative treatment but there is still a strong argument for surgical repair.
Without a doubt, one of the main downsides of surgical repair is a higher risk for complications, mainly in the form of infection and deep vein thrombosis (DVT). Minimally invasive techniques are by no means new but are now gaining popularity. Percutaneous technique first originated in 1977 with Ma and Griffith, who discussed the crossing of sutures over the Achilles tendon through six medial and lateral short skin incisions.2 The authors reported no complications but this approach did not allow for visualization of the repair, which put the sural nerve at risk for injury. The mini-open method was first described by Kakiuchi in 1995.3
Minimizing Surgical Risks In Achilles Tendon Repair
New advancements in minimally invasive surgical repair reportedly mitigate these common surgical risks. In addition, both percutaneous and mini-open techniques demonstrate strong repairs equivalent to those generated with more traditional open techniques. In a meta-analysis comparing open and minimally invasive techniques, McMahon and colleagues found that patients overall were more satisfied with minimally invasive surgical repair over open repair but both groups exhibited similar functional outcomes.4 New mini-open and percutaneous techniques with lower learning curves can reduce the risk of nerve damage and allow visualization of the repair without the complications associated with open repair.
Most studies and literature reviews show that operative treatment of Achilles tendon ruptures has a lower incidence of re-rupture than patients undergoing non-operative treatment. Meta-analysis publications on Achilles tendon ruptures in 2002 and 2012 demonstrated an 8.8 to 10.7 percent re-rupture rate when initial treatment was non-operative.5,6 The highest re-rupture rate for operative treatment reported in the literature is 3.6 percent.7
Bear in mind that this statistically significant difference was reported in studies that emphasized traditional immobilization methods. This means immobilization with non-weightbearing for at least six weeks and subsequent physical therapy. Admittedly, the re-rupture rate for nonoperative treatment can be lower when there are early functional rehabilitation protocols. Researchers have demonstrated that early functional rehabilitation reduces complications of tendon repair, re-rupture rates and DVTs after both operative and non-operative treatment.8,9
Olsson and colleagues set out to evaluate whether stable surgical repair and early loading of the tendon could improve patient-reported outcomes and function after an acute Achilles tendon rupture.10 They found that 10 percent of non-surgical patients had a re-rupture. None of the patients in the surgical group had a re-rupture. The study does conclude that there were no significant differences in physical activity level between the groups’ pre-injury level at six and 12 months.
One should take caution in regard to other studies on acute Achilles tendon ruptures reporting on functional status outcomes. Sample pools are often small and determining functional status, including sporting activity, is variably and often incompletely reported.11 In addition, methods of determining function are often not standardized.
Pertinent Points About Return To Activity And Maintaining Muscle Strength
Historically, open Achilles tendon repair has demonstrated earlier return to activity or, more importantly, to work in comparison to conservative care. As I mentioned above, early functional rehabilitation has narrowed or closed the gap between surgical and non-surgical treatment. There is still controversy, however, with regard to elite athletes and those in the military. Current practice tilts toward surgical intervention as studies have previously shown these patients return to full capacity faster than those treated with conservative care.
In a 2016 retrospective review, Renninger and team investigated results of operative and non-operative management of Achilles tendon ruptures in the active duty military population.12 Patients in the surgical group did have a statistically significant reduction in the time required to return to active duty of approximately 1.5 months, which may represent a clinically significant difference in highly active workers or highly active people. This is definitely something to consider with a certain subset of the patient population, including workers’ compensation patients.
With regard to muscle strength, historically, researchers have shown that there is less decrease in muscle strength with operative treatment.13 Operative fixation will reduce the risk of overlengthening of the tendon, thus maintaining muscle strength. Elongation of the Achilles tendon has a negative effect on the muscle push-off strength, produces gait abnormalities and lowers the power generated around the ankle. In addition, six weeks of immobilization averages a 10 percent decrease in calf circumference.13 Early functional rehabilitation has decreased tendon lengthening in the non-surgical group and has improved loss of calf circumference in both groups.13 Those who are not emphasizing early mobilization will increase their patients’ risk for muscle weakness.
Concluding Thoughts
In summary, controversy still exists as to the best treatment options for acute Achilles tendon rupture. With the rise in Achilles tendon injuries, a consensus is necessary for the management of acute ruptures. Surgical intervention is the superior option for younger, healthier, active patients. Advances in percutaneous and mini-open techniques have reduced the risk for infection, DVTs and nerve injury. This coupled with early functional rehabilitation can make surgical repair a more attractive option for the “gray zone” of operative candidates. It can also be the better option for those who need to return sooner to an active occupation, sports or military service.
Dr. Parthasarathy is in private practice in Silver Spring, Md. She currently serves on the Joint Committee on the Recognition of Specialty Boards, is Chair of the American Podiatric Medical Association (APMA) Social Media Working Group and serves on the APMA Marketing Committee. Dr. Parthasarathy was previously a Podiatry Section Chief at the Medstar Montgomery Medical Center in Olney, Md., and is a past recipient of the American Podiatric Medical Association’s Rising Star Award (2017), presented to members in recognition of outstanding national accomplishments in scientific, professional or civic endeavors.
No. Although the decision-making process is multifaceted, this
author contends that conservative treatment, especially in combination with a functional rehabilitation program, is a viable option for many patients with acute midsubstance Achilles tendon ruptures.
By Michael Loshigian, DPM, FACFAS
The management of acute Achilles tendon ruptures methodology has been controversial over the past decade. However, in recent years, there have been a plethora of original studies and and meta analyses that support a conservative, non-surgical treatment of this common injury.1-5 Non-surgical treatment is an acceptable and reliable course of management for the majority of acute midsubstance Achilles tendon ruptures with many authors recommending a short period of immobilization in an equinus attitude followed by early protected weightbearing and a functional rehabilitation program.
Outcomes of this conservative care methodology for acute midsubstance Achilles tendon ruptures produce reliably good functional outcomes as good or nearly as good as primary surgical repair.4-8 It is important to realize that this protocol applies to acute mid-substance Achilles ruptures and is not necessarily as applicable to neglected ruptures and chronic insertional Achilles degenerative tears. Appropriate patient selection includes consideration of the patient’s activity level and medical health. Evaluation of treatment success, whether surgical or non-surgical, should include measuring return to pre-injury function and activity level, patient satisfaction, strength, active range of motion, single leg heel raise and calf circumference.
What The Literature Reveals About Conservative Treatment
In several recent studies, there were no statistically significant differences in the results of non-surgical versus surgical treatment at one and two years post-injury.5,9,10 Another recent study by Lim and colleagues looked at 200 patients with acute Achilles tendon ruptures with 99 patients having surgical repair and 101 patients receiving nonoperative treatment.5 At two years, 62 patients in the surgical group and 70 patients in the non-operative group were available for follow up. Using the Achilles tendon total rupture score (ATRS) to evaluate functional status, the study authors reported no significant differences between the two treatment groups, male and female patients, or between younger (under age 40) and older patients.
In a 2010 study involving 97 patients with acute Achilles tendon ruptures, Nilsson-Helander and team assessed surgical and non-surgical treatment.8 Evaluating the patients six and 12 months after injury, the researchers assessed the degree of recovery by the aforementioned ATRS as well as functional tests and clinical examination. At six months, the surgical group had better results in comparison to the non-surgical group in regard to the above parameters. However, at the one-year evaluation, there were no statistically significant differences between the two treatment groups when it came to the level of function of the injured leg.
A review of relevant recent publications seems to concur in general that a functional rehabilitation protocol without surgery yields equivalent results at 12 to 18 months post-injury in comparison to surgical intervention. Also, there were only marginal benefits among surgically-treated patients in factors such as the height of single leg heel raise and jump testing.
Recognizing The Key Aspects Of A Functional Rehabilitation Protocol
There is some variability in what is considered to be a functional rehabilitation protocol. However, by comparing published methodologies from several authors, there are several common components.11 Most cite an initial period of three to four weeks of non-weightbearing immobilization in a gravity equinus cast followed by a period of partial- to full weightbearing as tolerated in a CAM boot incorporating some degree of equinus. Patients began physical therapy at approximately four to six weeks post-injury. By eight weeks, they could perform active and passive stretches as well as concentric and eccentric muscle-tendon unit strengthening, proprioception and balance exercises.
At approximately three months, patients were allowed to walk without an CAM boot or ankle-foot orthosis and begin light weightbearing aerobic exercises as well as single leg heel raise exercises.11 Patients resumed full intensity aerobic exercise activities in most cases at four to six months after initial treatment.
Critically Evaluating The Risks Of Surgical Repair: What You Need To Know
While some studies indicate earlier return to activity with surgical repair as well as marginally improved strength versus non-operative treatment with functional rehabilitation, one must weigh the pros and cons of surgical management along with the patient’s age, pre-injury activity level, and general medical condition when deciding between surgical versus non-operative management. Obesity, tobacco use, diabetes and peripheral arterial disease as well as use of corticosteroids or other drugs that have immunosuppressive effects are all factors that increase the complication rate of surgical repair.12,13
Complications of surgical repair of acute Achilles tendon ruptures can be significant and treatment of these complications can be costly. Stavenuiter and colleagues studied complications in a retrospective analysis of 615 adult patients who had operative repair for acute Achilles tendon ruptures.14 The incidence of complications was nearly 12 percent and included wound healing issues, deep infection, re-rupture, hematoma, nerve injury, deep vein thrombosis (DVT), and pulmonary embolism (PE). In addition, we have to consider the relative risks of anesthesia associated with surgical repair. In many studies, it seems that incurring the associated risks of surgical repair may provide at best a marginal benefit with regard to the final outcome versus non-surgical cohorts.14
Other Pertinent Considerations
The costs associated with surgical repair are undoubtedly higher as well. While this should not be a decision-making factor in recommending a course of treatment to our patients, the cost efficiency of medical care is an increasingly studied metric by government agencies and the commercial insurance sector.
Finally, it is possible that more recently available injectable biologic treatments such as amniotic tissue, stem cells, extracellular matrix, etc. may increase the rate of tissue repair and strength enough that non-surgical treatment including functional rehabilitation will become the standard of care in a broader patient population including the younger athletic patient.15 More research is necessary in order to fully assess the impact of these modalities for Achilles tendon ruptures.
In Conclusion
For many patients and possibly for the majority of acute Achilles tendon ruptures, non-surgical care via functional bracing and rehabilitation will yield consistently good reliable outcomes. It is important that we discuss this option in detail with our patients and consider the risk/benefit ratio as well as the financial impact of treatment in each individual case.
Dr. Loshigian has been in private practice in New York City since 1995. He holds voluntary staff appointments at New York Presbyterian Queens, NYU Langone Health and multiple hospitals in the Mount Sinai Health System. Dr. Loshigian is board-certified in foot surgery by the American Board of Foot and Ankle Surgery.
Point
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2. Ma GWC, Griffith TG. Percutaneous repair of acute closed ruptured Achilles tendon: a new technique. Clin Orthop Relat Res. 1977;128:247-255.
3. Kakiuchi M. A combined open and percutaneous technique for repair of tendo Achilles. Comparison with open repair. J Bone Joint Surg Br. 1995;77(1):60-63.
4. McMahon SE, Smith TO, Hing CB. A meta-analysis of randomised controlled trials comparing conventional to minimally invasive approaches for repair of an Achilles tendon rupture. Foot Ankle Surg. 2011;17:211-217.
5. Bhandari M, Guyatt GH, Siddiqui F, et al. Treatment of acute Achilles tendon ruptures: a systematic overview and meta analysis. Clin Orthop Relat Res. 2002;(400):190-200.
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10. Olsson N, Silbernagel KG, Eriksson BI, et al. Stable surgical repair with accelerated rehabilitation versus nonsurgical treatment for acute Achilles tendon ruptures: a randomized controlled study. Am J Sports Med. 2013;41(12):2867-2876.
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12. Renninger CH, Kuhn K, Fellars T, Youngblood S, Bellamy J. Operative and nonoperative management of Achilles tendon ruptures in active duty military population. Foot Ankle Int. 2016;37(3):269-273.
13. Heikkinen J, Lantto I, Flinkkilä T, et al. Augmented compared with nonaugmented surgical repair after total Achilles rupture: Results of a prospective randomized trial with thirteen or more years of follow-up. J Bone Joint Surg Am. 2016;98(2):85-92.
Counterpoint
1. Aujla RS, Patel S, Jones A, Bhatia M. Non-operative functional treatment for acute Achilles tendon ruptures: The Leicester Achilles Management Protocol (LAMP). Injury. 2019;50(4):995-999.
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3. Glazebrook M, Rubinger D. Functional rehabilitation for nonsurgical treatment of acute achilles tendon rupture. Foot Ankle Clin. 2019;24(3):387-398.
4. Kauwe M. Acute achilles tendon rupture: clinical evaluation, conservative management, and early active rehabilitation. Clin Podiatr Med Surg. 2017;34(2):229-243.
5. Lim CS, Lees D, Gwynee-Jones DP. Functional outcome of acute achilles tendon rupture with and without operative treatment using identical functional bracing protocol. Foot Ankle Int. 2017;38:1331-1336.
6. Lantto I, Heikkinen J, Flinkkila T, et al. A prospective randomized trial comparing surgical and nonsurgical treatments of acute achilles tendon ruptures. Am J Sports Med. 2016;44(9):2406-2414.
7. Manent A, Lopez L, Coromina H, et al. Acute Achilles tendon ruptures: efficacy of conservative and surgical (percutaneous, open) treatment-a randomized, controlled, clinical trial. J Foot Ankle Surg. 2019;58(6):1229-1234.
8. Nilsson-Helander K, Silbernagel KG, Thomee R, et al. Acute achilles tendon rupture: a randomized, controlled study comparing surgical and nonsurgical treatments using validated outcome measures. Am J Sports Med. 2010;38(11):2186-2193.
9. Lu J, Liang X, Ma Q. Early functional rehabilitation for acute achilles tendon ruptures: an update meta-analysis of randomized controlled trials. J Foot Ankle Surg. 2019;58(5):938-945.
10. Zhou K, Song L, Zhang P, Wang C, Wang W. Surgical versus non-surgical methods for acute achilles tendon rupture: a meta-analysis of randomized controlled trials. J Foot Ankle Surg. 2018;57(6):1191-1199.
11. Zellers JA, Christensen M, Kjaer IL, Rathleff MS, Silbernagel KG. Defining components of early functional rehabilitation for acute Achilles tendon rupture: a systematic review. Orthop J Sports Med. 2019;7(11):2325967119884071.
12. Dombrowski M, Murawski CD, Yasui Y, et al. Medical comorbidities increase the rate of surgical site infection in primary Achilles tendon repair. Knee Surg Sports Traumatol Arthrosc. 2019;27(9):2840-2851.
13. Hillam JS, Mohile N, Smyth N, Kaplan J, Aiyer A. The effect of obesity on achilles rupture repair. Foot Ankle Spec. 2019;12(6):503-512.
14. Stavenuiter XJR, Lubberts B, Prince RM 3rd, Johnson AH, DiGiovanni CW, Guss D. Postoperative complications following repair of acute achilles tendon rupture. Foot Ankle Int. 2019;40(6):679-686.
15. Shapiro E, Grande D, Drakos M. Biologics in Achilles tendon healing and repair: a review. Curr Rev Musculoskelet Med. 2015;8(1):9-17.
Other References
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21. Olsson N, Silbernagel KG, Eriksson BI, et al. Stable surgical repair with accelerated rehabilitation versus nonsurgical treatment for acute Achilles tendon ruptures: a randomized controlled study. Am J Sports Med. 2013;41(12):2867-2876.
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