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
Click here for another OrthoBuzz post about this JBJS Reviews article.
The fact that 12 of the 16 AAOS clinical practice guidelines for treating Achilles tendon ruptures are supported by “weak” or “inconclusive” evidence makes the recent JBJS Reviews article by Guss et al. on this subject all the more welcome.
The most emphatic point made by these authors is that functional rehabilitation protocols with early motion (and an associated shift away from long-term post-injury immobilization) have made a dent in the re-rupture rates historically seen with nonoperative treatment of Achilles tendon injuries, the incidence of which has increased in recent decades. The authors emphasize, however, that the delicate balance between loading and unloading of a healing Achilles tendon remains a rehabilitative challenge, and they encourage further research to identify which patients are more or less likely to experience success with nonoperative management.
The authors note also that the focus of outcomes research of different management methods has shifted from rates of re-rupture and infection to more specific functional measures—and, in some cases, to direct and indirect cost measures. For example, Guss et al. cite one meta-analysis that found that operatively treated patients returned to work almost three weeks earlier than those treated nonoperatively.
The authors also observe that the rate of deep vein thrombosis after Achilles rupture seems to be higher than that seen in other foot/ankle conditions, but they add that the majority of those thrombotic events are “unlikely to be clinically important.” Still, Guss et al. conclude that “prophylactic anticoagulation should be considered for older patients with an Achilles tendon rupture, including those treated nonsurgically.”