Operative versus Nonoperative Treatment

In an attempt to gather the best evidence available to guide treatment recommendations for Achilles tendon rupture, a literature search was performed using the search terms “Achilles,” “tendon,” “rupture,” “treatment,” “operative,” and “nonoperative.” Literature was then screened for Level I and II evidence comparing operative and nonoperative treatments of Achilles tendon ruptures. The search was narrowed to six studies (Table 69-1).

Three of the studies meet the criteria for Level 1 original evidence articles including randomized, control trials (RCT) by Cetti and investigators,¹⁶ Moller and researchers,²¹ and Nistor.²² Cetti and investigators¹⁶ randomized 111 healthy subjects, of which 90% were reported to regularly participate in sports, to operative repair (n = 56) or nonoperative treatment (n = 55) of their ruptured Achilles tendons. This study cites a rerupture rate of 5.4% and 14.5% for operative and nonoperative cohorts, respectively. The deep infection rate was 3.6% and 0% in favor of the nonoperative cohort. Furthermore, many complications rates were cited to be lower in the nonoperative group, as was the return to sport rate.

In the second Level I study, Moller and researchers²¹ cite similar results with a rupture rate of 1.7% versus 20.8% in the operative and nonoperative cohorts, respectfully. This study also cites decreased complications with a slower return to work time in the patients treated without surgery. The patients in both cohorts had similar demographic characteristics and were healthy, reporting a high level (70–80%) of regular participation in sports.

In the third Level I original evidence article, Nistor²² randomized 115 patients of similar health demographic characteristics to operative repair or nonoperative treatment of their ruptured Achilles tendon. Results reported included a 3% rerupture rate for both operative and nonoperative treatments, whereas the infection rate was 4.4% and 0% favoring nonoperative treatment. The minor complication rate was much greater (68.8% vs. 0%) in the nonoperative group.

The final three studies reviewed included Level I meta-analysis studies by Bhandari and colleagues²³ and Khan and coauthors,²⁴ and a Level II quantitative review of the literature by Wong and coauthors.²⁵ The most recent study by Khan combined the results of four studies,^{16,21, 22, 26} which included 356 patients. The cumulative rerupture rate was greater (12.6% vs. 4.6%) in the nonoperative group, but the infection (4.0% vs. 0%) and minor complication rates (33.5% vs. 2.7%) were lower.

In Bhandari and colleagues’²³ Level I meta-analysis study, six original articles were identified to meet all eligibility criteria.^{16,21,22,27–29} The cumulative rerupture rate was greater in the nonoperative group (13% vs. 3.1%; n = 448; P = 0.005), but the infection rate was lower (0% vs. 4.7%; n = 421; P = 0.03). No difference was cited in the return to function and the spontaneous complaints cumulative data.

Finally, Wong and coauthors’²⁵ quantitative review of the literature pooled data gathered from 125 articles including 5370 patients. This study identifies no difference in the rerupture rate between operative and nonoperative cohorts (1.4% vs. 1.5%) but does cite an increased wound complication rate in the operative cohort (14.6% vs. 0.5 %).

Percutaneous versus Open Operative Repair

A literature search was performed using the search terms “Achilles,” “tendon,” “rupture,” “treatment,” and “operative,” “open,” “percutaneous,” and “surgery.” Literature was then screened for Level I and II evidence comparing percutaneous and open operative treatments of Achilles tendon ruptures; three studies were found^30–32 (see Table 69-1).

The best article currently available is a Level I RCT with a patient population of 66 (33 patients in each of the open and percutaneous cohorts) by Lim and coauthors.³² Patients in these cohorts were described as more sedentary (30% regular participation in sports) with no information on health status. Results cited a lower rerupture rate in patients treated with percutaneous repair versus open repair (6% vs. 2%); however, the differences in these results were not statistically significant. However, a statistically significant increase in the infection rate for patients treated with open repair (21% vs. 0%) was reported. Sural nerve complications, adhesions, and perceived functional outcomes were greater in the percutaneous repair, although again they were not statistically significant.