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Surgery is no better than nonoperative treatment for Achilles tendon rupture in adults
Clinical Question
Is open repair or minimally invasive surgery better than nonoperative management for adults with acute Achilles tendon rupture?
Bottom line
There is no clear benefit to surgery over nonoperative management for adults with acute Achilles tendon rupture. Symptomatic improvement is the same, and surgery trades more nerve injuries for a lower risk of re-rupture. 1b
Reference
Study design: Randomized controlled trial (nonblinded)
Funding: Government
Setting: Inpatient (any location) with outpatient follow-up
Synopsis
The Achilles heel of orthopedic surgery appears to be that whenever surgeons compare one of their favorite procedures to nonoperative management, they find that nonoperative management is effective for many, if not all, patients. In this Norwegian study, adults aged 18 to 60 years with an acute Achilles tendon rupture were randomized to receive open surgical repair, minimally invasive repair, or nonoperative management. The injury had to be assessed and casted within 3 days of injury, and surgery had to happen by day 7 from injury. The nonoperative management involved a below-the-knee equinus cast for 2 weeks, followed by 6 weeks of weight-bearing as tolerated with heel wedges and ankle-foot orthoses. Patients had gradually decreasing plantar flexion with progressive removal of heel lifts in the 6 weeks following the equinus cast. The brace was worn day and night for the first 2 weeks but was removed at night for weeks 2 through 6. The postoperative management of surgical patients was similar. Groups were similar at baseline, with a mean age of 40 years, body mass index of approximately 27, and about 75% were men. Analysis was by intention to treat, and allocation was appropriately concealed, although of course the study was not masked to the intervention. At 1 year, there was no difference in the primary outcome of a change in the Achilles tendon Total Rupture Score compared with baseline status pre-injury: -17 points for nonoperative treatment, -16 points for open repair, and - 14.7 points for minimally invasive surgery. In this case, smaller negative numbers are better, but the minimal clinically important difference is estimated to be 8 to 10 points. There was also no difference in the broader Short Form (36) Health Survey quality of life scale. Nerve injuries were less common with nonoperative management (0.6% vs 2.8% with open repair and 5.2% with minimally invasive surgery). However, re-ruptures were more common with nonoperative management (6.2% vs 0.6% in each of the surgery groups, number needed to treat to harm = 18), with most occurring in the 10 weeks following the index injury.
Reviewer
Mark H. Ebell, MD, MS
Professor
University of Georgia
Athens, GA
Comments
Surgery is no better than nonoperative treatment for Achille
If it says:
“ However, re-ruptures were more common with nonoperative management (6.2% vs 0.6% in each of the surgery groups, number needed to treat to harm = 18), with most occurring in the 10 weeks following the index injury.”
Then that suggests surgical outcome is better.
Defering surgical repair of Achilles tendon rupture and res
Though the study showed comparatively equal results in both lines I personally feel the surgical repair is preferable unless patients have co morbid conditions,lack of fitness for anaesthesia and patients who can't afford. This is why because 1-the study sample volume was not available
2- the possibility of re rupture is a tough task to handle because of the probability of scarring and fibrosis resulting in less vascular areas and delay in healing.
3 the unreliable patient's compliance and obedience in maintaining the cast , non weight bearing gait and
Existing co morbidities are likely affect the outcome adversely
Non surgical treatment of Achilles tendon rupture
The term "rupture" means complete transection of the tendon with retraction of margins. There is no way these two margins can come together spontaneously.
Tendon ruptures
I think there was a significant underestimate on how long a tendon needs to heel without operative intervention. Even the extensor tendon on the fingers fails often if you only give it 2 mth and does a lot better with 3-4 months of neglible traction
Improving medical and surgical care
This is welcome outcomes research putting medical care to the ultimate test. It is humbling but also satisfying to see exactly where we stand in terms of medico-surgical treatments. This can only help the future of medicine and surgery even (?especially?) if some of our favourite ideas and opinions are de-bunked!
achilles tendon rupture
conservative treatment, not surgery, is better