Surgical Versus Nonsurgical Treatment of Acute Achilles Tendon Rupture

Objective To compare the incidence of reruptures and the functional outcomes of patients with acute Achilles tendon rupture treated with or without surgery in addition to identical rehabilitation protocols. Design Randomized controlled unblinded trial, with 1 year of follow-up. Sample size was calculated with 80% power to show a previously observed difference of 19% in rerupture rates between treatments at P ≤0.05. Setting The emergency department at the Sahlgrenska University Hospital, Gothenburg, Sweden, in the period 2004 to 2007. Participants Persons between 16 and 65 years of age with a unilateral Achilles tendon rupture (based on medical history, tendon palpation, and the Thompson test) 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 disease. The included patients were 79 men and 18 women, with a mean age of 41 years. The groups did not differ in age, sex, stature, side of injury, and whether their work was sedentary or heavy. Intervention Surgery was performed on 49 patients by orthopedic surgeons familiar with the modified Kessler suture technique. A longitudinal medial skin and paratenon incision was made, and the Achilles tendon was repaired using an end-to-end suture. The paratenon was repaired, and the skin was closed. After surgery, the patients were placed in a below-the-knee cast with the foot in 30 degree equinus position. The nonsurgical group (n = 48) were treated immediately with a similar cast. All patients kept the cast on for 2 weeks, when it was replaced by a brace for 6 weeks. The brace was adjusted by a physiotherapist to allow full flexion and to gradually increase dorsiflexion from −30 to +10 degrees. All patients followed a supervised standardized progressive exercise program from weeks 11 to 24 (or longer) and then started a group exercise program and a gradual return to sports. Main Outcome Measures The primary outcome was occurrence of rerupture. Secondary outcomes were patient-reported Achilles tendon rupture scores and a physical activity scale and function evaluations using the MuscleLab (Ergotest Technology) measurement system, which included jump, strength, and muscular endurance tests. Patients were assessed at 6 and 12 months by 2 independent physiotherapists. Main Results There were 6 reruptures in the nonsurgical group compared with 2 in the surgical group (difference, 8.42%; 95% confidence interval, −2.46% to 19.3%). Achilles tendon rupture scores improved during rehabilitation for both groups (P < 0.001), but they did not differ between groups. Physical activity scale scores did not differ between groups but remained lower for both groups than before injury (P < 0.05). Complications of surgery included 1 Achilles tendon contracture, 2 infections, and 2 nerve disturbances on the side of the foot. The rate of deep vein thrombosis was 34% and did not differ between groups. After 6 months, 2 endurance tests, hopping, and a strength test were superior in the surgical group (P ≤ 0.05), but at 12 months, only heel-rise work remained superior (P < 0.012). The function of the injured leg was poorer than that of the uninjured leg after 6 and 12 months. Conclusions Rerupture rates and patients' assessment of their function were similar after surgical or nonsurgical treatment for acute ruptures of the Achilles tendon. Some strength and endurance tests improved earlier in the surgery group.