Background It is unclear whether surgical repair of an acute Achilles tendon rupture using an open or minimally invasive repair approach is associated with better outcomes than nonsurgical treatment. Methods We conducted a multicenter, randomized, controlled trial comparing nonsurgical treatment, open repair, and minimally invasive surgery in adults with acute Achilles tendon rupture presenting at four trial centers. The primary outcome was the change from baseline in total Achilles tendon rupture score (scores range from 0 to 100, with higher scores indicating better health status) at 12 months. Secondary outcomes included the incidence of tendon rerupture. Results A total of 554 patients were randomized and 526 patients were included in the final analysis. The mean changes in total Achilles tendon rupture score were −17.0 points in the nonsurgical group, −16.0 points in the open repair group, and −14.7 points in the minimally invasive surgery group ( p = 0.57). Pairwise comparisons provided no evidence of differences between groups. Changes from baseline in physical performance and self-reported physical function were similar in all three groups. The number of tendon ruptures was higher in the nonsurgical group (6.2%) than in the open repair or minimally invasive surgery group (0.6% each). There were 9 nerve injuries in the minimally invasive surgery group (in 5.2% of patients) compared with 5 in the open repair group (in 2.8%) and 1 in the nonsurgical group (in 0.6%). Conclusions In patients with Achilles tendon rupture, surgery (open repair or minimally invasive surgery) was not associated with better outcomes than conservative treatment at 12 months. (Funded by the Regional Health Authority of Southeast Norway and Akershus University Hospital; ClinicalTrials.gov number, NCT01785264. opens in new tab.) |
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A torn Achilles tendon can reduce a weekend warrior to a limper. And there is no single right way to deal with it. People who have suffered this common injury may do as well with physical therapy as they do with surgery, a new clinical trial shows.
The Achilles tendon is the largest tendon in the body and connects the calf muscles to the heel bone. When it ruptures, often during high-impact sports or exercise, the tendon fibers break and separate.
Studies have suggested that, on average, people with Achilles tendon ruptures have similar outcomes whether they undergo surgery to reattach the tendon or only receive rehabilitation therapy.
But those studies have been small, said Dr. Stale Myhrvold, principal investigator of the new trial. That makes it harder to detect differences in longer-term problems, such as the chances of a tendon tear recurring, according to Myhrvold, an orthopedic surgeon at Akershus University Hospital in Norway.
His team’s study of more than 500 Norwegian patients found that without surgery, the risk of a new rupture was actually higher.
However, patients who underwent surgery sometimes suffered nerve injuries related to the procedure, which almost all nonsurgical patients were able to avoid. And over a year, patients reported similar improvements in their daily functioning whether they underwent surgery alone or rehabilitation.
The results, Myhrvold said, suggest that "most acute Achilles tendon ruptures in adults can be treated nonoperatively, with results similar to surgical treatment." But a US orthopedic surgeon warned that the results of a carefully controlled trial don’t always translate cleanly to the real world.
Dr. Andrew Elliott, a foot and ankle surgeon at the Hospital for Special Surgery in New York City, pointed out an important detail: Patients in the study were placed in a special cast to immobilize the foot and ankle within the 72 hours after injury.
That’s much faster than is typical in daily practice, according to Elliott, who said it can be a week or 10 days after the injury before he sees patients and can put them in casts. Beyond that, Elliott said, the choice to have surgery or not depends "first and foremost" on the individual patient.
For an athlete or a very active person, for example, surgery may be the best option. Without it, Elliott said, the tendon will heal, but not necessarily in the ideal way. Surgery can fix it more precisely, at its proper length and tension.
On the other hand, Elliott said, the nonsurgical approach might be better for older patients, smokers and those who have health problems that may make surgery riskier. And, of course, there are patient preferences: Some are eager to avoid surgery, while others "don’t even want to talk about nonsurgical options," Elliott said.
The study was published April 14 in the New England Journal of Medicine. It involved 554 patients with a newly ruptured Achilles tendon, mostly men between 30 and 40 years old. They were randomly assigned to three groups: one non-surgical; one who had traditional "open" surgery and another who had minimally invasive surgery, performed through a small incision.
