AJSM PreView, published on August 27, 2010 as doi:10.1177/0363546510376052
Acute Achilles Tendon Rupture
A Randomized, Controlled Study Comparing
Surgical and Nonsurgical Treatments Using
Validated Outcome Measures
Katarina Nilsson-Helander,*yz MD, PhD, Karin Grävare Silbernagel,z§ PT, PhD,
Roland Thomeé,z PT, PhD, Eva Faxén,z PT, Nicklas Olsson,z MD,
Bengt I. Eriksson,z MD, PhD, and Jon Karlsson,z MD, PhD
Investigation performed at the Sahlgrenska University Hospital, Gothenburg, Sweden
Background: There is no consensus regarding the optimal treatment for patients with acute Achilles tendon rupture. Few randomized
controlled studies have compared outcomes after surgical or nonsurgical treatment with both groups receiving early mobilization.
Purpose: This study was undertaken to compare outcomes of patients with acute Achilles tendon rupture treated with or without
surgery using early mobilization and identical rehabilitation protocols.
Study Design: Randomized, controlled trial; Level of evidence, 1.
Methods: Ninety-seven patients (79 men, 18 women; mean age, 41 years) with acute Achilles tendon rupture were treated and
followed for 1 year. The primary end point was rerupturing. Patients were evaluated using the Achilles tendon Total Rupture Score
(ATRS), functional tests, and clinical examination at 6 and 12 months after injury.
Results: There were 6 (12%) reruptures in the nonsurgical group and 2 (4%) in the surgical group (P 5 .377). The mean 6- and 12month ATRS were 72 and 88 points in the surgical group and 71 and 86 points in the nonsurgical group, respectively. Improvements in ATRS between 6 and 12 months were significant for both groups, with no significant between-group differences. At the
6-month evaluation, the surgical group had better results compared with the nonsurgically treated group in some of the muscle
function tests; however, at the 12-month evaluation there were no differences between the 2 groups except for the heel-rise work
test in favor of the surgical group. At the 12-month follow-up, the level of function of the injured leg remained significantly lower
than that of the uninjured leg in both groups.
Conclusion: The results of this study did not demonstrate any statistically significant difference between surgical and nonsurgical
treatment. Furthermore, the study suggests that early mobilization is beneficial for patients with acute Achilles tendon rupture
whether they are treated surgically or nonsurgically. The preferred treatment strategy for patients with acute Achilles tendon rupture remains a subject of debate. Although the study met the sample size dictated by the authors’ a priori power calculation, the
difference in the rerupture rate might be considered clinically important by some.
Keywords: Achilles tendon rupture; movable brace; rerupture; ATRS; validated functional tests
Treatment protocols for patients with acute Achilles tendon rupture are constantly being modified. Both surgical
and nonsurgical therapies are followed by immobilization
in a cast or a movable brace. However, despite several
randomized studies, there is no consensus regarding the
optimal treatment protocol.|| Meta-analyses generally
agree that the rerupture rate is higher in patients treated
nonsurgically (12.6%) than in patients treated surgically
(3.5%), but the risk varies considerably in previous studies.3,9,11,15,16,35 Surgically treated patients have an
increased risk of other complications such as infections,
wound problems, and nerve injuries.26 Furthermore,
regardless of treatment type, patients often have residual
weakness and decreased function after Achilles tendon
rupture.9,18,19,21,25
*Address correspondence to Katarina Nilsson-Helander, MD, PhD,
Department of Orthopaedics, Kungsbacka Hospital, SE-434 40 Kungsbacka, Sweden (e-mail: ina.nilsson@telia.com).
y
Department of Orthopaedics, Kungsbacka Hospital, Kungsbacka,
Sweden.
z
Department of Orthopaedics, Institute of Clinical Sciences at Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University
Hospital, Gothenburg, Sweden.
§
University of Delaware, Newark, Delaware.
The authors declared that they had no conflicts of interests in their
authorship and publication of this contribution.
The American Journal of Sports Medicine, Vol. XX, No. X
DOI: 10.1177/0363546510376052
Ó 2010 The Author(s)
||
References 4-7, 14, 17, 19, 20, 27, 28, 32, 34.
1
2
Nilsson-Helander et al
There are large variations in the treatment protocols
used for patients with acute Achilles tendon rupture. The
initial decision is whether treatment should be surgical
or nonsurgical. If surgery is chosen, the literature
describes many different techniques that include both
open and percutaneous repairs.35 The optimal approach
is, however, still not clear.
Furthermore, in the last few decades, postoperative
treatment and initial protocol for nonsurgically treated
patients has changed from cast immobilization for 6 to 8
weeks to the use of a functional brace that allows immediate mobilization for both groups. The increased use of functional braces is associated with a decrease in rerupture
rates in both surgically and nonsurgically treated
patients.17,27,28,31,34 The rerupture rate decreases from
approximately 5% to 2.3% when using a functional brace
instead of a cast in surgically treated patients, and from
12.2% to 2.4% in nonsurgically treated patients.9 Studies
have also shown that the patients’ opinion of their quality
of life was superior when a functional postoperative protocol was followed.17 However, it is difficult to draw definitive conclusions because studies vary considerably in
terms of the specific treatment protocols and methodology.
The present study is a continuation of a previous study19
that reported a rerupture rate of 1.7% in patients treated
with surgery and 20.8% in patients treated nonsurgically.
The nonsurgically treated group, however, underwent 8
weeks of cast immobilization, whereas the surgically treated
group received a movable brace.19 Because the treatment
protocols for the 2 groups differed, it was difficult to judge
whether the surgery, the early range of motion, or the combination of both was the reason for the superior outcomes in
the surgically treated group. Validated outcome measures
are now available,23,30 making it possible to improve our
understanding of how various treatments affect outcomes
after acute Achilles tendon rupture.
The purpose of the present study was to compare outcomes of patients with acute Achilles tendon rupture treated with or without surgery using identical mobilization
and rehabilitation protocols.
METHODS
Patients
One hundred patients with acute Achilles tendon rupture
who sought medical attention at the emergency department at the Sahlgrenska University Hospital, Gothenburg,
Sweden, were included in a prospective, randomized study
from 2004 to 2007. In all patients, the diagnosis was established based on medical history and clinical examination
(tendon palpation and Thompson test33). Patients eligible
for the study were randomized to receive either surgical
treatment or nonsurgical treatment. Computer-generated
sealed envelopes were used in the randomization procedure that was administered by the study coordinator.
Because of diversity in reporting, we do not know how
many patients were included out of the total number of
patients who sought medical attention for acute Achilles
tendon rupture at the emergency wards.
The American Journal of Sports Medicine
TABLE 1
Patient Baseline Characteristicsa
Variable
Age
Gender
Male
Female
Height, cm
Injured side
Right
Left
Work
Sedentary
Light but mobile
Heavy
Surgical
(n 5 49)
Nonsurgical
(n 5 48)
P
Value
40.9 (8.8)
41.0 (24.0; 59.0)
n 5 49
41.2 (9.5)
39.0 (23.0; 63.0)
n 5 48
.9367
40 (81.6%)
9 (18.4%)
178.7 (9.2)
180.0
(154.0; 197.5)
n 5 47
39 (81.3%)
9 (18.8%)
177.7 (8.8)
180.0
(153.0; 192.0)
n 5 40
23 (46.9%)
26 (53.1%)
27 (56.3%)
21 (43.8%)
.4753
15 (30.6%)
23 (46.9%)
11 (22.4%)
15 (31.9%)
27 (57.4%)
5 (10.6%)
.3708
1.0000
.6362
a
For categorical variables, data are reported as n and (%). For
continuous variables, data are reported as mean (standard deviation), median (min; max), and n. For comparisons between groups,
the Fisher exact test was used for dichotomous variables, MantelHaenzsel x2 exact test was used for ordered categorical variables,
and the Mann-Whitney U test was used for continuous variables.
Patients between 16 and 65 years of age with a unilateral Achilles tendon rupture were included in the study if
they were randomized and treated within 72 hours of the
injury. Exclusion criteria were diabetes mellitus, previous
Achilles tendon rupture, other lower leg injuries, immunosuppressive therapy, and neurovascular diseases.
Two patients who were randomized to receive nonsurgical treatment opted to receive surgical treatment. One
patient who was randomized to the surgical treatment
group was treated nonsurgically because it was not possible to perform the surgery within 72 hours. Therefore, 97
patients (79 men and 18 women) were included in the
follow-up evaluations (Table 1).
All participants received oral and written information
about the purpose and procedures of the study and provided written informed consent. Ethical approval was
obtained from the Regional Ethical Review Board in Gothenburg, Sweden.
Treatment Procedure
Surgical Group. Forty-nine patients were treated surgically. Surgery was performed with the patient in the prone
position under local, spinal, or general anesthesia. A tourniquet was used for hemostasis in 27% of the patients.
After a longitudinal 5- to 8-cm medial skin and paratenon
incision, an end-to-end suture was placed using a modified
Kessler suture technique8 and 1-0 polydioxanone (PDS)
sutures (PDS II, Ethicon, Somerville, New Jersey) (Figure 1).
The paratenon was carefully repaired and the skin closed
with interrupted nylon sutures. Surgery was performed by
Vol. XX, No. X, XXXX
Acute Achilles Tendon Rupture
3
TABLE 2
Rehabilitation Protocol
Figure 1. A schematic view of the surgical technique used.
1 of 28 orthopaedic surgeons familiar with the technique.
Postoperatively, the patients were placed in a below-theknee cast with the foot in 30° equinus position.
In the surgically treated group, thromboprophylaxis
consisting of 500 mL of high molecular-weight dextran
was administered according to a specific protocol. No
standard thromboprophylaxis was administered to the
nonsurgically treated group.
Nonsurgical Group. Forty-eight patients composed the
nonsurgical group. The patients were treated immediately
with a below-the-knee cast with the foot in equinus position.
Surgical and Nonsurgical Groups. All patients in both
groups were treated with a below-the-knee cast with the
foot in equinus position for 2 weeks, followed by an adjustable brace (DonJoy ROM Walker, DJO Nordic AB, Malmö,
Sweden) for the next 6 weeks. The brace was set at free plantar flexion motion with dorsiflexion limited to 230° the first
2 weeks, 210° the next 2 weeks, and 110° the last 2 weeks.
Weightbearing as tolerated was allowed after 6 to 8 weeks.
The brace was adjusted by a physiotherapist. The patients
were not allowed to remove the brace themselves.
Rehabilitation
All patients followed a standardized rehabilitation
protocol (Table 2) under the supervision of 2 experienced
physiotherapists.
Weeks 8-11
Treatment: Shoe with a heel-lift (1.5 cm), crutches as needed for
another 1-3 weeks
Exercise program: Visit to physical therapist 2-3 times/wk and
home exercises daily
Exercise bike
Ankle range of motion
Sitting heel-rise
Standing heel-rise (2 legs)
Gait training
Balance exercises
Leg press
Leg extension and leg curl
Weeks 11-16
Treatment: Shoe with a heel-lift (1.5 cm) until week 16
Exercise program: Visit to physical therapist 2-3 times/wk and
home exercises daily
Exercises as above with increased weight
Standing heel-rise increase to hold at end range of
plantar flexion on 1 leg
Step
Walking on mattress
Weeks 16-20
Exercise program: Visit to physical therapist 2-3 times/wk and
home exercises
Exercises as above with increase in weights and intensity as
tolerated
Slide
Quick rebounding heel-rises
From week 18
Heel-rise in stairs
Side jumps
2-legged jumps
Week 20-24
Exercise program: Visit to physical therapist as needed
Exercises as above with increase in weights and intensity as
tolerated
Jog
Side jumps forward
Week 24 and onward
Exercise program: Continued physical therapy if needed
Start group exercise class (similar to aerobics)
Gradual return to sports (dependent on patient ability)
history, symptoms, general function, scar inspection, and
evaluation for loss of sensitivity of the foot. The patients
were not examined for comorbidity.
Screening for deep vein thrombosis (DVT) was performed by color duplex sonography 8 weeks after treatment was initiated.12
Evaluation of function, symptoms, and physical activity
level was performed at 6 and 12 months after the injury by
2 experienced independent physiotherapists.
Follow-up Evaluation
All patients received follow-up examinations at the orthopaedic department at 2, 8, and 12 weeks and at 6 and 12
months after injury. Examinations were performed mainly
by the first author (K.N.-H.), including such elements as
Patient-Reported Outcome and Physical Activity
The patients’ symptoms and physical activity levels were
assessed using the Achilles tendon Total Rupture Score
(ATRS) and a physical activity scale (PAS).23,29 The
4
Nilsson-Helander et al
ATRS ranges from 0 to 100; a lower score indicates more
symptoms and greater limitation of physical activity. For
the PAS, a score of 1 equals no physical activity, whereas
a score of 6 equals heavy physical exercise several times
per week.
Functional Evaluations
The MuscleLab (Ergotest Technology, Oslo, Norway) measurement system was used for functional evaluations.
MuscleLab is a data collection unit to which sensors of different kinds can be connected. The test battery consisted of
2 different jump tests, 2 different strength tests, and 1
muscular endurance test. The test battery has been shown
to be reliable and valid for evaluating lower leg function in
patients with Achilles tendinopathy and was performed as
described by Silbernagel et al.30 The tests were also used in
a recent study that evaluated outcomes of chronic rupture
and rerupture of the Achilles tendon.22 The jump tests
were a drop counter-movement jump (drop CMJ) and hopping. For the drop CMJ, the patients started by standing
on 1 leg on a 20-cm-high wooden box. They were instructed
to ‘‘fall’’ down onto the floor and, directly on landing, perform a maximum vertical 1-legged jump. The maximum
jumping height in centimeters was used for data analysis.
Hopping was a continuously rhythmical jump similar to
skipping. The patients performed 25 jumps, the average
air flight and floor contact times were documented, and
the plyometric quotient (flight time/contact time) was
used for data analysis. The strength tests were a concentric
heel rise and an eccentric-concentric heel rise. For the
strength tests, a linear encoder was used. A spring-loaded
string was connected to a sensor inside the linear encoder
unit. When the string was pulled, the sensor gave a series
of digital pulses proportional to the distance traveled. The
resolution is approximately 1 pulse every 0.07 mm. By
counting the number of pulses/time, the displacement as
a function of time can be recorded and thus allow calculation of time, length, velocity, force, and power (force 3
velocity). In this experiment, the spring-loaded string of
the linear encoder was attached to the heel of the participant’s shoe and thus the height (in centimeters) and time
(in seconds) of the heel displacement of the heel-rise could
be measured. The weight of the participant and the extra
external weight were entered into the MuscleLab software
and peak power in watts was calculated. The best trial (ie,
with the highest power in watts) for each weight was used
for data analysis.
The muscular endurance test was a standing heel-rise
test. The total amount of work performed (in joules) and
the maximum heel-rise height were used for data analysis.
All patients were given standardized instructions and the
tests were then demonstrated by the physiotherapist.
The subjects also performed 3 to 5 practice trials prior to
testing. Verbal encouragement was used and athletic footwear was standardized. Before testing, the patients
warmed up by cycling for 5 minutes on a stationary bicycle,
followed by 3 sets of 10 two-legged toe raises. The uninjured side was always tested first.
The American Journal of Sports Medicine
Statistical Analysis
All data were analyzed using SPSS 15.0 for Windows
(SPSS, Chicago, Illinois). Descriptive data are reported as
mean, median standard deviation, and range (minimummaximum).
The power calculation that was conducted before the study
started was based on a previous study from our hospital in
which there was a rerupture rate of 1.7% (surgical treatment)
versus 20.8% (nonsurgical treatment).19 For an 80% power,
a sample size of 50 patients per group was needed.
Rerupture of the Achilles tendon was the primary end
point in the study. The Fisher exact test was used for
dichotomous variables. For comparison between the 2
groups, Mantel-Haenzsel x2 exact test was used for ordered
categorical variables and Mann-Whitney for continuous
variables. The Wilcoxon signed rank test was used to evaluate differences between the injured and uninjured sides,
as well as differences before injury and after treatment.
The Mann-Whitney U test was used to compare the 2
groups of patients. The level of significance was set at
P \ .05. The limb symmetry index (LSI) was calculated
to compare the 2 treatment groups. The LSI was defined
as the ratio between the involved limb score and the uninvolved limb score, expressed as a percentage (involved/
uninvolved 3 100 5 LSI).
RESULTS
Rerupture
There were 6 (12%) reruptures in the nonsurgically treated group and 2 (4%) in the surgically treated group (P 5
.377). One patient in the surgically treated group suffered from a second rerupture.
Patient-Reported Outcome and Physical Activity
The patients in the surgically treated group had a mean
ATRS of 72 points (median, 75; range, 31-100) at the 6month follow-up visit and 88 points (median, 93; range,
30-100) at the 12-month evaluation. The patients in the
nonsurgically treated group had a mean ATRS of 71 points
(median, 75; range, 32-100) at the 6-month evaluation and
86 points (median, 90; range, 31-100) at the 12-month evaluation. Both groups improved significantly (P \ .001) over
time; however, there were no significant differences
between the 2 groups at either the 6-month or 12-month
evaluations (P 5 .870 and P 5 .441, respectively).
Eighty-six percent of the ruptures in the present study
occurred during sports activities; racket sports accounted
for 50%.
The mean PAS preinjury score was 4.31 for the surgical
group and 4.39 for the nonsurgical group. The mean PAS
score for the surgical group was 3.4 (median, 3.0; range,
1-6) at the 6-month evaluation and 3.6 (median, 3.0; range,
1-6) at the 12-month evaluation. The mean PAS for the
nonsurgical group was 3.3 (median, 3.0; range, 2-6) at
the 6-month evaluation and 3.7 (median, 4.0; range, 2-6)
Vol. XX, No. X, XXXX
Acute Achilles Tendon Rupture
5
TABLE 3
Functional Test Performance Scores for Patients with Achilles Tendon Rupture at 6 and 12 Months Postinjurya
6-Month Evaluation
Test
Heel-rise work
Heel-rise height
Hopping
Drop CMJ
Concentric power
Eccentric power
12-Month Evaluation
Nonsurgical
Surgical
P Value
n 5 37
54% (20)
17-102
n 5 38
68% (15)
42-121
n 5 38
75% (35)
0-109
n 5 37
76% (18)
0-106
n 5 38
71% (32)
21-161
n 5 38
60% (29)
0-116
n 5 45
65% (17)
36-100
n 5 45
75% (12)
46-103
n 5 45
90% (24)
0-126
n 5 45
79% (16)
38-110
n 5 45
82% (26)
26-140
n 5 45
70% (21)
26-119
.013
.009
.037
.379
.050
.110
b
Nonsurgical
Surgical
P Valueb
n 5 40
68% (20)
20-119
n 5 41
77% (13)
49-113
n 5 38
90% (30)
0-133
n 5 40
83% (16)
34-108
n 5 40
82% (33)
29-180
n 5 40
72% (20)
24-133
n 5 45
78% (20)
28-113
n 5 45
81% (13)
47-103
n 5 46
101% (16)
68-144
n 5 44
88% (17)
44-139
n 5 45
87% (24)
42-151
n 5 45
79% (19)
49-135
.012
.053
.222
.179
.295
.193
a
For test variables: n 5 /mean (standard deviation)/ min-max. Mann-Whitney U test was used to evaluate differences between the nonsurgical and surgical groups. CMJ, counter-movement jump.
b
Boldface type indicates significant difference.
at the 12-month evaluation. There were no significant differences between the 2 groups at the 6- and 12-month evaluations (P 5 .38 and P 5 .71, respectively); however, both
groups had a significantly reduced PAS at the 6- and 12month evaluations relative to their preinjury levels.
Complications
One patient in the surgically treated group sustained an
Achilles tendon contracture, and even though reoperation
was performed, the patient still reported severe symptoms
and difficulties with normal gait and physical training.
Color duplex sonography screening showed a high incidence
of DVT (34%).24 Two infections occurred in the surgical
group, 1 deep and 1 superficial. The patient with a deep
infection was treated with wound dressings and antibiotics;
the other patient received local treatment. Two patients in
the surgical group complained of nerve disturbances on
the lateral side of the foot. Thirteen patients had complaints
concerning the scar, with cosmetic complaints in 10 patients
and concerns about decreased ankle function attributable to
scar contracture and pain in 3 patients.
Functional Tests
Nonsurgical Versus Surgical Group at 6 and 12 Months.
Table 3 shows LSI at the 6- and 12-month evaluations for all
functional tests. Performances on the concentric strength,
heel-rise height, and hopping tests were significantly better
in the surgical group than in the nonsurgical group at the
6-month evaluation (P 5 .05, P 5 .009, and P 5 .037,
respectively); however, there were no significant differences
at the 12-month evaluation (P 5 .295, P 5 .053, and P 5
.222, respectively). On the heel-rise work test, the surgical
group performed significantly better than the nonsurgical
group at both the 6-month and 12-month evaluations (P 5
.013 and P 5 .012, respectively). There were no betweengroup differences in performance on the drop CMJ or eccentric strength test at either the 6- or 12-month evaluations.
Injured Versus Uninjured Side. Both groups had significantly lower values for the injured leg than the uninjured
leg in all tests at both the 6- and 12-month evaluations,
except for the hopping test at 12 months for which no difference was found. The injured leg improved significantly
over time in both groups (Table 4).
DISCUSSION
There were no significant differences in rerupture rate
between the surgical and nonsurgical treatment groups.
Furthermore, there were no significant differences between
the groups with regard to the patients’ own opinions about
their symptoms and function or their physical activity
levels at the 6- and 12-month evaluations. The surgical
group achieved a greater improvement in function (concentric strength, heel-rise work/height, and hopping) at
the 6-month evaluation than did the nonsurgical group;
however, there were no differences between groups at
the 12-month evaluation, except on the heel-rise work
test in which the surgical group performed significantly
better than the nonsurgical group. Both groups improved
in function during the 12 months of follow-up, but still
had significantly decreased function in the injured leg
6
Nilsson-Helander et al
The American Journal of Sports Medicine
TABLE 4
Performance on Functional Tests for the Injured Versus Uninjured Leg at the 6- and 12-Month Evaluationsa
6-Month Evaluation
Test
Heel-rise work
(nonsurgical)
Heel-rise work
(surgical)
Heel-rise height
(nonsurgical)
Heel-rise height
(surgical)
Hopping
(nonsurgical)
Hopping (surgical)
Drop CMJ
(nonsurgical)
Drop CMJ
(surgical)
Concentric power
(nonsurgical)
Concentric power
(surgical)
Eccentric power
(nonsurgical)
Eccentric power
(surgical)
Injured
Uninjured
n 5 38
n 5 38
1590 (984)
2926 (1097)
250-4903
1107-6377
n 5 45
n 5 45
1919 (737)
2978 (938)
891-4146
1001-4909
n 5 39
n 5 38
9.6 (2.6)
14.0 (2.2)
5.0-17.9
10.3-21.6
n 5 45
n 5 45
10.6 (2.2)
14.1 (2.1)
5.9-17.3
9.4-18.8
n 5 39
n 5 38
0.386 (0.194) 0.518 (0.127)
0.0-0.78
0.35-0.89
n 5 45
n 5 45
0.465 (0.161) 0.513 (0.119)
0.0-0.84
0.29-0.85
n 5 39
n 5 37
10.2 (3.4)
13.5 (3.6)
0-18
6-23
n 5 45
n 5 45
10.5 (3.7)
13.3 (4.0)
4-21
6-22
n 5 39
n 5 38
194 (115)
274 (99)
42-543
114-558
n 5 45
n 5 45
238 (122)
302 (141)
73-732
117-929
n 5 39
n 5 38
226 (132)
381 (151)
0-575
210-762
n 5 45
n 5 45
290 (106)
429 (141)
89-585
73-732
Comparison, 6- and 12-Month
Evaluations
12-Month Evaluation
P Valueb
\.001
\.001
\.001
\.001
\.001
.005
\.001
\.001
\.001
\.001
\.001
\.001
Injured
Uninjured
n 5 40
n 5 41
2078 (1095) 3101 (1440)
342-5955
1199-8665
n 5 45
n 5 45
2373 (936)
3083 (1121)
510-4683
1049-5519
n 5 41
n 5 41
10.7 (2.4)
14.0 (2.4)
7.3-16.9
9.5-21.6
n 5 45
n 5 45
11.1 (2.2)
13.8 (2.0)
5.7-15.2
9.3-18.1
n 5 40
n 5 39
0.447 (0.182) 0.497 (0.145)
0.0-0.80
0.0-0.91
n 5 46
n 5 46
0.536 (0.142) 0.536 (0.141)
0.31-0.91
0.32-0.91
n 5 40
n 5 40
11.6 (4.1)
14.0 (4.2)
3-20
4-23
n 5 44
n 5 44
11.8 (4.0)
13.4 (3.8)
6-22
7-23
n 5 41
n 5 40
223 (96)
299 (136)
96-521
90-809
n 5 46
n 5 45
258 (100)
311 (138)
87-664
113-869
n 5 41
n 5 40
292 (149)
418 (182)
107-884
176-946
n 5 45
n 5 46
344 (132)
443 (158)
153-899
198-1074
P Valueb Injured P Valueb Uninjured P Valueb
\.001
\.001
\.001
\.001
\.001
.008
\.001
.001
.317
\.001
.007
.242
.083
.003
.613
.764
.004
.407
\.001
.001
.330
\.001
\.001
.536
.001
.009
.881
\.001
.090
.210
\.001
\.001
.060
\.001
\.001
.296
a
For continuous variables: n 5 /mean (standard deviation)/ min-max. Wilcoxon signed rank test was used to evaluate differences between
the injured and uninjured side, as well as differences between 6-month and 12-month evaluations. CMJ, counter-movement jump.
b
Boldface type indicates significant difference.
relative to the uninjured leg. The importance of, and reasons for, the seemingly better performance in some of
the muscle function tests, unrelated to the patient’s own
opinion, are unclear and thus further studies are needed.
Early mobilization was initiated in both the surgical and
the nonsurgical group because evidence in the literature
indicates that early mobilization with mechanical loading
of the tendon appears to improve the healing process.2,10
Favorable results when using early mobilization have
been reported for both surgically and nonsurgically treated
patients with acute Achilles tendon rupture.1,27,28,34 In the
present study, we attempted to use the exact same treatment protocols for both groups, except for surgery. Surgically treated patients had, in the present study,
a rerupture rate of 4%, similar to that reported in the
meta-analyses of Bhandari et al3 and Khan et al.9 We
enrolled 100 patients and, with the treatment protocol
employed, the rerupture rate in nonsurgically treated
patients was dramatically lowered compared with a previous
study.19 Although the study met the sample size dictated by
our a priori power calculation, the difference in the rerupture rate might be considered clinically important by some.
Our results strengthen previous recommendations to
use a functional brace instead of rigid cast fixation. The
fact that the number of patients included in the present
study was limited, as in most other studies, means that
the results of each patient have a substantial effect on
the overall results. Therefore, larger studies are needed
to evaluate the effect of functional bracing and early range
of motion training.
Vol. XX, No. X, XXXX
According to a meta-analysis by Bhandari et al,3 the
rerupture rate with surgical treatment (3.1%) was significantly lower than with nonsurgical treatment (13%). However, the authors pointed out that there were wide
confidence intervals in the included studies. One major
problem among the studies is the variation in methodological quality. In a meta-analysis by Khan et al,9 the rerupture
rates were estimated at 3.5% and 12.6% in surgically and
nonsurgically treated patients, respectively. Other authors
have pointed out that surgical treatment is associated
with a higher rate of other complications, such as infections,
wound problems, nerve injuries, and adhesions after surgery.25,26 Early weightbearing and mobilization with or
without surgical treatment is suggested to produce the
best result, provided that the tendon ends are in contact.1
When following a large group of patients with acute
Achilles tendon rupture, it is important to consider that
some patients experience rerupture because of accidents
during normal activities of daily living, regardless of treatment type. The reasons for the accidents are many, but
sometimes patients do sustain rerupture for no obvious
reason, as was the case for 3 of the patients in the present
study. Six patients in the nonsurgical group sustained
rerupture, 2 of whom were noncompliant with the study
protocol. However, it is not known whether noncompliance
was the reason for rerupture. One patient sustained
a rerupture because of a fall. All the patients with rerupture underwent successful reoperation as described by
Nilsson-Helander et al.22 Two reruptures occurred in the
surgical group. One patient slipped on the floor 2 weeks
after injury and was successfully treated with extended
immobilization with the brace locked; the other had
a wound infection and sustained a rerupture 2 months
after the infection had healed. This patient also suffered
from a second rerupture despite reoperation.
With regard to the patients’ opinions of their own symptoms, function, and physical activity level, we found no significant differences between groups at the 6- or 12-month
evaluations. The ATRS for both groups improved significantly over time, but neither group achieved full recovery
as per the ATRS at the 12-month follow-up. In the future,
it would be helpful to evaluate whether the patients continue to improve over time or if their symptoms persist
long term. Both groups also had significantly reduced
physical activity levels at the 6- and 12-month evaluations
relative to their preinjury levels. This could be explained
by insufficient recovery, changes in their desired physical
activity level, or fear of reinjury.
The surgical group had significantly better results in
the heel-rise work, heel-rise height, concentric power,
and hopping tests at the 6-month evaluation than did the
nonsurgical group. However, at the 12-month evaluation,
there was a significant between-groups difference only in
the heel-rise work test. There were no significant differences in performance on the drop CMJ or the eccentric
strength tests between the 2 groups at the 6- or 12-month
evaluations. However, for both groups, there were significant differences between the injured and uninjured sides
on all tests at the 6-month evaluation, with deficits
ranging from 10% to 46%. At the 12-month evaluation,
Acute Achilles Tendon Rupture
7
significant deficits persisted for all tests except for the hopping test, with deficits ranging from 12% to 32%. These
results underscore the importance of using several functional tests for evaluating treatment outcome, as in the
present study.
It is possible that patients treated nonsurgically require
a longer recovery period and that this was reflected in the
greater functional deficits at the 6-month evaluation. It is
also possible that the nonsurgical group had been more cautious during rehabilitation than the nonsurgical group and
therefore their strength/endurance had not improved at
the same pace. However, it remains that normalization of
function of the injured leg relative to the uninjured leg
was not achieved in either group at 12 months, which is in
accordance with other studies.19,27 Further studies are
needed to evaluate whether greater improvements could be
achieved with other types of treatment protocols. Furthermore, a follow-up time of 1 year is probably too short to
determine whether normalization can be achieved over time.
We have no explanation for the Achilles tendon contracture sustained by 1 patient in the surgically treated group.
This patient reported being healthy overall. However, even
after reoperation, the patient reported severe symptoms
and difficulties with normal gait and physical activity 1
year after the initial injury. The 2 cases of infection that
occurred in the surgical group, as well as the other wound
and nerve complications, are similar to that reported in the
literature. Thirteen patients complained about the scar,
with 10 patients concerned about the aesthetics and 3
reporting decreased ankle function attributable to scar
contracture and pain. Although scar complications are generally minor, they can be troublesome for some patients.
Color duplex sonography revealed 32 patients with
DVT, which coincides with results presented in a recent
study by Lapidus et al.13 Because DVT appears to be common after acute Achilles tendon rupture, a routine thromboprophylaxis protocol should be established for these
patients. These results are reported separately.24
The short-term results might favor the surgical group in
terms of function, but this benefit does not translate to
patient-reported symptoms. Surgical treatment appears to
be associated with a lower rate of rerupture, but the absolute number of reruptures was low in both groups. Power
calculation in the present study is based on clinically relevant differences as commented upon above; however, type
II error cannot be excluded. The number of patients
included in the present study could also be too low to detect
a significant between-groups difference in this regard. Other
complications such as DVT, infection, and scar complaints
need to be considered when evaluating treatment options.
Clinically, it is important to consider the type of treatment to use for each individual patient, weighing the risk
of a rerupture against the risk of complications, the functional outcome in terms of muscle function, and the patients’
own opinion about their symptoms and capacity.
In conclusion, the results of this study did not demonstrate any statistically significant difference between surgical and nonsurgical treatment. Furthermore, the study
indicates that early mobilization is beneficial for patients
with acute Achilles tendon rupture whether they are treated
8
Nilsson-Helander et al
surgically or nonsurgically. The preferred treatment strategy for patients with acute Achilles tendon rupture remains
under debate. Larger, high-quality multicenter studies that
evaluate both the occurrence of complications, including
rerupture, and patients’ symptoms and function are needed
to determine the optimal course of treatment for the individual patient with acute Achilles tendon rupture.
ACKNOWLEDGMENT
The authors thank Lotta Falkheden-Henning and Annelie
Brorsson for their help treating and evaluating the
patients. They also thank the Swedish National Centre
for Research in Sports (CIF) and the local Research and
Development Council of Halland, Sweden, for providing
financial support.
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