AAOS 2009: Nonsurgical Rehab After Achilles Tendon Rupture Better Than Surgery

Barbara Boughton

March 02, 2009

March 2, 2009 (Las Vegas, Nevada) — Nonoperative treatment of Achilles tendon ruptures, when combined with early and accelerated rehabilitation, produces similar results to surgery, with fewer complications, according to a randomized clinical trial presented here at the American Academy of Orthopaedic Surgeons 2009 Annual Meeting. The Canadian study, which assessed results for up to 2 years after Achilles tendon injury, found that patients experienced comparable flexibility, strength, and recurring rupture rates after both treatments.

"There is a lot of bias, especially in the United States, toward surgical treatment of Achilles tendon ruptures," said lead researcher Kevin Willits, MD, from the Fowler Kennedy Sport Medicine Clinic at the University of Western Ontario, in London. "For some people, it's almost like a religion — they believe that surgery should be the standard of care. But studies on both methods of treatment have actually been conflicting and equivocal," he said.

Dr. Willits and colleagues aimed to answer lingering questions about treatment for Achilles tendon ruptures with a prospective randomized trial that carefully assessed patients for up to 2 years. They hypothesized that when combined with accelerated rehabilitation, nonsurgical care would decrease rerupture rates without complications.

In the trial, 145 patients at 2 sports medicine centers in Canada were randomized to either surgical or nonsurgical treatment. Those randomized to surgery underwent a standard suture-based repair followed by an accelerated rehabilitation program beginning 2 weeks after surgery. Those randomized to nonsurgical care were fitted with an Aircast boot with a 2 cm heel wedge immediately upon presentation, and crutches for 2 weeks, followed by the same type of accelerated rehabilitation protocol.

Rehabilitation therapy for both groups consisted of early protected weight-bearing and range-of-motion activities with a boot and heel lift. Patients removed the lift at 6 weeks and the boot at 8 weeks, after which weight-bearing activities were encouraged. Patients in both groups were a mean age of 40.9 years, had similar height and weight characteristics, and included a similar number of men and women. To be included in the study, patients were required to have a complete Achilles tendon rupture, as diagnosed by a positive Thompson test fewer than 14 days from their injury.

Recurring Rupture Rate Similar

Results indicated that after 2 years, rerupture rates in both groups were almost the same, with 2 reruptures in the surgery group and 3 in the nonsurgery group, a difference that was not statistically significant. There was also a greater number of serious adverse events in the surgery group (1 deep vein thrombosis and 1 pulmonary embolism) than in the nonsurgery group (1 deep vein thrombosis). Three patients in the surgery group also developed deep infections requiring irrigation and debridement. In all, there were 2.6 times more complications in the surgery group than in the nonsurgery group, Dr. Willits said.

Assessments of strength and flexibility were performed 3 and 6 months and 1 and 2 years after treatment, and showed no difference between groups. The mean modified Leppilahti score was 78.2 in the surgery group and 79.7 in the nonsurgery group (95% confidence interval; P = .55). Measurements of mean side-to-side plantar flexion and calf circumference were –2 and –1.4, respectively, in the surgery group, and –0.9 and –1.6 in the nonsurgery group, and the differences were not significant.

Dr. Willits attributed the low rate of complications seen in the study — in both surgery and nonsurgery groups — to the aggressive rehabilitation program. Both groups experienced significant improvement in range of motion and strength between 1 and 2 years, which Dr. Willits also attributed tothe accelerated rehabilitation program.

Potentially Practice-Changing

"This is a great study and a landmark paper, and it's a model of how to perform a randomized controlled trial," commented Paul Fortin, MD, director of foot and ankle surgery at the William Beaumont Hospital, in Royal Oak, Michigan, who moderated the session at which the paper was presented. "The data are very clean and it's potentially practice-changing." However, he noted that a 2-year follow-up may not have been long enough to capture all reruptures among the study's patients.

"You can't follow patients forever," Dr. Willits responded. He noted that most Achilles tendon reruptures occur within 3 months after treatment, and assessments done for 2 years should capture most reruptures.

"We hope that our study will be 1 piece of evidence that helps settle the debate about whether surgery or nonsurgical treatment is the better method after Achilles tendon ruptures," he said.

The study was funded by Physician Services Inc. and the Aircast Foundation. Dr. Willits has disclosed research support from Aircast. Dr. Fortin disclosed no relevant financial relationships.

American Academy of Orthopaedic Surgeons (AAOS) 2009 Annual Meeting: Abstract 673. Presented February 27, 2009.


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.