Achilles Ruptures: to operate or not?
Over 2000 years since Homer first wrote about the mythical hero from which the Achilles is named, debate as to how best treat ruptures of this tendon still rages fiercely. Traditional dogma stated that all ruptures (except in the very old or those with multiple comorbidities) required an operation to achieve the best possible functional outcome. The figure of nine times greater risk of re-rupture when treated non-operatively is often quoted, I only very recently overheard a junior doctor state this statistic to a patient. However, with modern rehabilitation methods, does this re-rupture rate still apply to non-operatively treated patients? Are there still advantages of operative over non-operative treatment?
With increasing participation in weekend sport and activities, rupture rates worldwide in women and men have risen. Diagnosis can frequently be made on clinical history and examination. A history of a sudden onset of pain in the posterior calf, "I looked around to see who shot me" with a palpable defect in the tendon and an abnormal Thompson's (calf squeeze) test are very suggestive. Either USS or MRI can be used to confirm the diagnosis, but delays in arranging such tests can result in a delay in instigating optimal treatment.
Traditionally, surgical treatment was combined with six weeks of immobilisation postoperatively. However, since the 1980s there has been an increasing focus on early postoperative functional rehabilitation. The term functional rehabilitation implies early weight bearing in a brace, along with a range of motion protocol that increases on a weekly basis. Cycling with one leg and hydrotherapy (deep water running) exercises can be incorporated as often as early as week two.
There have now been three well designed randomised controlled trials (RCT) examining whether operative treatment is superior to non-operative functional management. The results paint a mixed picture. One trial reported no difference in functional scores, although there was a trend towards increased plantarflexion strength in the operative group. Another found that counterdrop and hopping sub-scores at 12 months were significantly better in the operative group. The final RCT showed that although there were significant functional differences between the groups at six months, by twelve months this difference had disappeared. Although not statistically significant, in all three trials there was a trend towards increased ruptures in the non-surgical group. Interestingly, all three trials contained an upper age limit on the higher end (70) and made no comment on the relative preoperative fitness level of their patient cohorts.
To add further complexity, surgery for achilles tendon ruptures has evolved significantly over the last 10 years. All three RCTs listed above compared traditional open procedures (where incisions were up to 10cm long) with non-operative treatment. Newer techniques, including percutaneous and mini-open are thought to decrease significantly this risk of wound complications. To finally put the ambiguity of this issue to rest, a further RCT comparing non-operative functional rehabilitation to mini-open or percutaneous methods needs to be conducted. What do I tell my patients? The best available evidence shows that there is still a trend, albeit not statistically significant, towards improved function in operative patients. However, the functional improvements afforded by surgery are likely to be subtle and may not be noticed by all. However, for those playing a moderate or high level of sport these subtle deficits might make a significant difference to performance. Some trials suggest operations decrease re-rupture rates, although not statistically significant. However, with any operation, the small risk of wound complications needs to be considered, which although mitigated in mini-open techniques, is still present.
The key message of all literature is that operative and non-operative patients both have improved outcomes with early functional treatment. Gone are the days of non-weight bearing and cast immobilisation.
Dr Meghan Dares
409 Crown Street
Phone: 02 4201 7930