What Is the Best Treatment for Achilles Tendon Rupture?

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Chapter 69 What Is the Best Treatment for Achilles Tendon Rupture?

Achilles tendon ruptures (Fig. 69-1) are a catastrophic event that occurs when forces that are placed on the Achilles tendon exceed its tensile limits (approximately strain >8%).¹ This event is likely a result of a preexisting Achilles tendon disease²^–⁴ if the forces are relatively low. The histopathology of the diseased human Achilles tendon has been previously described on the basis of biopsies from the Achilles tendons of patients with subcutaneous rupture^3,⁵^–⁹ and chronic, localized Achilles tendon symptoms.^6,^{10, 11} These studies suggest that a common pathologic process may predispose individuals to rupture.^3,⁶

FIGURE 69-1 Ruptured Achilles tendon.

The most common patient profile for human Achilles tendon rupture would be that of a man in his third or fourth decade of life who plays sports occasionally. Men-to-women rupture ratios have been reported from 2:1 to 12:1.^2,^{4, 12} The mean age has been estimated between the 30s and 40s,¹³ with the left Achilles rupture more common than the right probably reflecting right-side dominance with left leg pushing off.¹⁴ Leppilahti and colleagues¹³ report on an increasing incidence of rupture in 1994 in Oulu, Finland, to be 18 per 100,000, whereas Suchak and coworkers¹⁵ report the incidence to be between 5.5 and 9.9 ruptures per 100,000 in North America. Subjects have been participating in sports during rupture at rates from 44.4% to 83%,^16,¹⁷ with 52.3% of ruptures playing badminton. The site of rupture has been reported to occur in the myotendinous junction in 12.1%, the insertion in 4.6%, and 3.5 cm proximal to the insertion in 83% of patients.⁴

The intention of this chapter is to provide the best evidence available for the treatment of Achilles tendon ruptures. It is divided into four sections including operative versus nonoperative treatment, percutaneous versus open operative treatment, and postoperative functional rehabilitation. Final treatment recommendations are based on the literature presented combined with clinical experience of overall patient care needs.

TREATMENT

Level I and II evidence evaluating operative and nonoperative treatment of Achilles tendon rupture are based on healthy patients. The surgical approaches of open repair and percutaneous repair are consistent. However, the specific surgical technique for open and percutaneous repairs may vary by suture technique and suture material. The variation in suture technique and material is not believed to be clinically significant because the strength of the repair is equivalent.

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).

TABLE 69-1 Summary of the Evidence Available That Should be Considered When Choosing Treatment Options for a Ruptured Achilles Tendon

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 researchers ²¹ 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, Nistor ²² 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 colleagues ²³ 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.

The second Level I study by Goren and researchers ³¹ was an RCT comparing isokinetic strength and range of motion after percutaneous (n = 10) and open (n = 10) surgical repair of a ruptured Achilles tendon. The study cites no difference in health status of the two cohorts. Results indicate that isokinetic strength and range of motion were equal in the two cohorts; however, there was an increased incidence of Sural nerve injury (40% vs. 0%) in the percutaneous-treated cohort.

Cretnik and colleagues’³⁰ Level II, prospective, nonrandomized study compares 237 patients with an Achilles tendon rupture treated with open (n = 105) versus percutaneous (n = 132) surgical repair. The results revealed slight increases in rerupture (3.7% vs. 2.8 %) and sural nerve injury (4.5% vs. 2.8%) rates in the percutaneous cohorts, but these differences were not statistically significant. However, fewer major (4.5% vs. 12.4%) and total complications (9.7% vs. 21%) were reported in the percutaneous cohort. Functional assessment using Foot and Ankle society score and the Holtz score demonstrated no differences between the two cohorts.

Postoperative Rehabilitation

A literature search was undertaken to compare postoperative rehabilitation methods for treatment outcomes of patients with cast immobilization versus “functional rehabilitation” using the search terms “Achilles,” “tendon,” “rupture,” “treatment,” “operative,” “cast,” “immobilization,” “rehabilitation,” “functional,” and “postoperative.” Literature was then screened for Level I and II evidence, identifying nine articles ³³^–⁴⁰ (see Table 69-1). Eight Level 1 original articles were RCTs, which were all in favor of early functional rehabilitation when compared with more traditional means of cast immobilization. The ninth article was a Level I meta-analysis pooling the results of six of the above articles.

Cetti and colleagues’³³ article was the first Level I article to compare the outcomes of patients using a mobile cast (n = 30) versus a rigid below-knee cast (n = 30). No significant difference in rerupture and infection rates was found in the two cohorts, but the mobile cast cohort was reported to have fewer minor complications, improved functional outcome, less elongation of the tendon, and was more likely to return to work.

Saleh and investigators ⁴¹ report results from a Level I study of functional rehabilitation with a full weight-bearing brace that holds the foot in 15 degrees of plantar flexion. The authors report a more rapid return of ankle dorsiflexion and return to normal activities.

Mortensen and researchers’³⁸ Level I study randomized 71 patients with an acute Achilles rupture to either cast immobilization for 8 weeks or early restricted motion of the ankle in a below-the-knee brace for 6 weeks. They also found that the increased motion cohort had improved functional outcome with respect to range of motion and a quicker return to sports or work.

Kerkhoffs and coworkers’³⁶ Level I study randomized a total of 39 consecutive patients with complete ruptures of the Achilles tendon to a walking cast or a wrap and showed that the wrap cohort allowed a significantly shorter hospital stay, as well as return to preinjury sports level compared with treatment with a walking cast. No increased risk of rerupture or wound healing problems were reported.

Costa and colleagues’³⁴ Level I study randomized 28 patients to either immediate loading in an orthosis or traditional serial plaster casting and showed improved clinical functional outcomes in the immediate loading group.

Kangas and coauthors’⁴² level I study randomized 50 patients treated surgically for an acute Achilles tendon rupture to receive either early movement or immobilization. The calf muscle strength results were somewhat better in the early motion group, whereas other outcome results obtained in the two cohorts were similar.

Finally, Maffulli and coworkers’³⁷ Level I study showed that patients who were randomized to an early weight-bearing protocol had shortened the time of recovery without increased complications.

In contrast with the studies detailed earlier, Kauranen and researchers’³⁵ and Petersen and investigators’³⁹ Level I study showed no improvement in outcome for patients treated with and with an active brace and CAM walker versus a plaster cast after surgical repair of acute Achilles tendon ruptures.

A Level I meta-analysis by Suchak and colleagues ⁴⁰ included six prospective RCTs^33,^{34, 37, 38, 42, 43} that were pooled to include 315 patients treated with surgical repair and postoperative immobilization (n = 156) or early functional rehabilitation (n = 159). The pooled results showed no difference in the rerupture rate in the immobilized and functional rehabilitation cohorts (3.8% vs. 2.5%, respectively) and no difference in the infection rates (3.8% vs. 3.1%, respectively). However, the functional rehabilitation cohort had improved subjective responses (88% vs. 62%) and less complications (e.g., scar adhesions and transient sural nerve deficits) (5.8% vs. 13.5%). The authors conclude that early functional rehabilitation for postoperative care of Achilles tendon ruptures treated with surgery improves patient satisfaction with reduced minor and major complications.

RECOMMENDATIONS

With respect to the choice of operative versus nonoperative care, one must consider patient factors that are detrimental to healing, infection, and a patient’s ability to undergo surgery. If patients have such factors, then the recommended treatment should be nonoperative care based on increased complication rates such as infection and wound healing (Levels of Evidence I and II, grade A recommendation), which are summarized earlier. If patients are free of such factors, then faster return to normal activities and less chance of rerupture is likely with operative care (Levels of Evidence I and II, grade A recommendation).

With respect to a recommendation on the type of surgical repair (open vs. percutaneous), one must consider patient factors that are detrimental to healing or infection. Thus, with patient factors that are absent for healing or infection concerns, one should choose open operative repair to avoid excessive risk to the sural nerve (Levels of Evidence I and II, grade A recommendation). If patient factors that affect healing or infection rates adversely are present, one may recommend percutaneous over open surgical repair to avoid wound healing and infectious complications (Levels of Evidence I and II, grade A recommendation). However, to make recommendations on operative percutaneous repair of a ruptured Achilles versus nonoperative care, then direct Level I or II studies comparing the two would be necessary.

Finally, it is strongly recommended with support from the existing literature (Levels of Evidence I and II, grade A recommendation) that that early functional rehabilitation for postoperative care of Achilles tendon ruptures treated with surgery improves patient function and satisfaction, and in some cases, reduces minor and major complications. Table 69-2 provides a summary of recommendations for the treatment of Achilles tendon rupture.

TABLE 69-2 Summary of Recommendations

STATEMENT	LEVEL OF EVIDENCE/GRADE OF RECOMMENDATION	REFERENCES
1. Patients free of factors that are detrimental to healing, infection, and ability to undergo surgery then operative treatment will provide faster return to normal activities and less chance of re-rupture.