Among the topics that consistently stimulate debate among orthopaedic surgeons is the treatment of acute Achilles tendon rupture. The central question is typically, “Should this injury be treated operatively or nonoperatively?” In the April 2015 issue of JBJS Reviews, Guss et al. tackle this question.
The decision to treat acute Achilles tendon rupture has always been a trade-off between wound complications (associated with operative treatment) and the risk of rerupture (associated with both nonoperative and operative treatment but more commonly associated with nonoperative treatment). While the authors quote numerous reports, an important observation among all of the reports cited is that rehabilitation protocols for nonoperative treatment were not uniform across cohorts. Considering recent findings, the debate about operative vs. nonoperative intervention apparently has shifted from a focus on rerupture and infection to a focus on functional outcomes. Functional rehabilitation protocols have decreased the rerupture rate historically seen in association with the nonoperative treatment of these injuries. Operative treatment may provide some functional benefits, but recent studies suggest that many of these benefits are transient or subtle.
Guss at al. also point out that the rate of deep-vein thrombosis after Achilles tendon rupture may be higher than that observed in association with many other foot and ankle conditions. Indeed, the incidence of deep-vein thrombosis in patients with acute Achilles tendon rupture is possibly as high as one in three, but the vast majority of deep-vein thromboses are asymptomatic and are unlikely to be clinically relevant. Prophylactic anticoagulation should be considered for older patients with Achilles tendon rupture, including those managed nonoperatively, as well as for patients with other known risk factors.
In summary, recent reports have suggested that the use of functional rehabilitation in lieu of cast immobilization has, to a certain extent, reduced the higher rates of rerupture that historically have been associated with nonoperative treatment. Moreover, functional rehabilitation protocols are not associated with the wound complications that are inherently associated with operative repair. Operative repair may provide functional benefits, but reports have suggested that these benefits may be transient or incremental and limited to those patients who participate in more intense athletic endeavors. Indeed, more research with well-designed, randomized clinical trials is necessary to clarify the potential for incremental functional gain following operative repair as well as to identify those patients in whom nonoperative treatment is more likely to fail.
Thomas A. Einhorn, MD, Editor
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