11th May 2022, Dr Chee L Khoo
I was fortunate to have received ample orthopaedic experience in my training days. I was all destined to be an orthopaedic surgeon but changed my mind. I have seen a few complete Achilles tendon rupture and assisted in many successful surgical repair. Conceptually, you can’t imagine how anyone can plantar flex again if the tendon ends are not reattached surgically. But then, if you are a hammer, everything looks like a nail. If you are a surgeon, and you hold a scalpel, everything must be surgically fixed. Can Achilles tendon rupture be treated non-surgically? Is the final outcome as good as surgery?
An acute Achilles’ tendon rupture is a fairly common musculoskeletal injury, with an annual incidence of 5 to 50 events per 100,000 persons and can result in severe disability (1-3). It is more common with older age, more active lifestyles and in males (4). There have been many randomised controlled trials (RCTs) comparing open repair of the tendon and non-surgical treatment and the outcomes and physical performance of both approaches have been similar (5,6). Like most surgical RCTs, the numbers involved are often small and the non-surgical intervention protocols are often varied and sometimes, incompletely described, making comparisons difficult.
Non-surgical treatments are known to have higher risks of re-rupture although surgical interventions are not totally immune from re ruptures either. Surgical treatment on the other hand can be complicated by infections and nerve damage as the Achilles tendon area is not well vascularised.
Minimally invasive surgery has been developed to reduce the risk of surgical complications. RCTs comparing open repair, minimally invasive surgery and non-surgical treatment are limited and once again, the numbers involved are often small (7-10). That is, until recently.
Stale B. Myhrvold et al from Norway performed a multi-center, randomised, controlled trial that compared nonoperative treatment, open repair and minimally invasive surgery in adults with acute Achilles’ tendon rupture who presented to four trial centers.(11) The primary outcome was the change from baseline in the Achilles’ tendon Total Rupture Score (ATRS). The scores range from 0 to 100, with higher scores indicating better health status at 12 months. Secondary outcomes included the incidence of tendon re-rupture.
Patients between 18-60 years who sustained an acute Achilles tendon rupture were assessed for eligibility. Patients who had previous Achilles tendon rupture, were of receipt of quinolones or local glucocorticoid injections (in the area of the Achilles’ tendon) in the 6 months before the injury, were dependent on walking aids and other disabilities related to walking were excluded. Between 2013 – 2018, of a total of 1084 patients that were enrolled into the study. After exclusion 526 patients who were randomised 1:1:1 to either non-operative treatment, open repair, or minimally invasive surgery had complete data for analysis.
The ATRS is a patient-reported assessment designed to measure outcomes in patients treated for acute Achilles’ tendon rupture. The questionnaire consists of 10 questions to assess symptoms and the level of physical activity. They also assessed physical performance using the MuscleLab measurement system which consists of two different jump tests, two different strength tests, and one muscular endurance test.
What did they find at the end of 12 months follow up?
The change in the ATRS from baseline to the 12-month follow-up was −17.0 points in the nonoperative group, −16.0 points in the open-repair group, and −14.7 points in the minimally invasive surgery group (p = 0.57). In other words, there were no difference in the ATRS whether patients were treated non-operatively, open repair or minimally invasive surgery.
When they compared non-operative treatment with open repair, there was a 1.0 point mean change in the ATRS. When they compared non-operative treatment with minimally invasive surgery, the mean change in ATRS was -2.6 points. When they compared open repair with minimally invasive surgery, the mean score difference was -1.2 points.
There were no apparent differences among the groups in the changes in the ATRS at 3 months and 6 months.
How safe were the treatments?
There were 11 reruptures in the non-operative group (in 6.2% of the patients), 1 in the open-repair group (in 0.6%), and 1 in the minimally invasive surgery group (in 0.6%); no patient had more than 1 rerupture. Half the reruptures occurred within the first 10 weeks (range, 2 to 28) after injury.
There were 9 nerve injuries in the minimally invasive surgery group (in 5.2% of the patients) as compared with 5 in the open-repair group (in 2.8%) and 1 in the nonoperative group (in 0.6%).
Overall, the number of nerve injuries was small across the intervention groups. The higher rates of reruptures in the non-operative group didn’t matter anyway since the ATRS were similar at 3,6 or 12 months.
In summary, they found no significant differences in changes in the Achilles’ tendon Total Rupture Score among patients who had been randomly assigned to receive nonoperative treatment or undergo open repair or minimally invasive surgery. There were also no appreciable differences among the groups in the secondary outcomes. The risk of rerupture was higher with nonoperative treatment than with either of the operative treatments but the overall numbers were small.
Thus, the next time your patient who suffered an acute Achilles tendon rupture and is discharged from emergency department with a non-surgical treatment, you can assure him or her that the 12 months results are similar to the surgical options. That is provided physiotherapy is part of the treatment.
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