Should You Cast Achilles Tendon Ruptures?

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By Troy J. Boffeli, DPM

Critical analysis of the evidence allows the evidence-based medicine (EBM) practitioner to determine if these results are applicable to the patient in question. Foot and ankle surgeons should determine if their surgical procedure, surgical skill level and patient are comparable to what the research described.
The desired outcome of treatment must reflect the individual patient’s values, concerns and expectations of care. The surgeon needs to look beyond the re-rupture rate and consider the individual patient’s risk tolerance for adhesion, infection and disturbed sensation. Surgeons have always pondered whether the potential benefits of surgery outweigh the risks.
The EBM practitioner must go two steps further by pondering whether the potential benefits of surgery outweigh the risks based on critical analysis of the best available evidence, considering the values and goals of individual patients. No RCT was designed to compare post-op functional bracing directly to non-operative treatment using a functional brace.
Consider the case of a 40-year-old, healthy, active male with a diagnosed acute Achilles rupture. Bear in mind that other Achilles rupture populations include high level athletes, those with delayed presentation Achilles ruptures, and elderly or sedentary adults with acute rupture and re-ruptures that develop after operative or non-operative treatment. Having a well defined clinical problem is important as treatment recommendations may vary from one population to another.
Nevertheless, one can make patient care decisions for the aforementioned 40-year-old patient. First of all, the traditional plantarflexed, non-weightbearing cast is not the optimal treatment for acute ruptures. When it comes to acute Achilles ruptures treated with or without surgery, one should use a removable brace that allows plantarflexion and immediate weightbearing while preventing dorsiflexion.
Second, surgery does not improve the functional result in comparison to non-operative treatment with a functional brace. Third, surgery may not actually decrease the re-rupture rate, although further research is needed that directly compares surgical versus conservative treatment with functional bracing for both groups. Finally, surgery has a much higher risk of minor complications like adhesion, infection and disturbed sensation.

In Conclusion

Based on a critical analysis of the best available evidence, active, healthy adults with acute Achilles rupture should undergo conservative treatment with functional bracing and early weightbearing. Results from the aforementioned RCTs may not be applicable to other Achilles rupture populations including high level athletes, those with delayed diagnosis of the rupture and re-rupture after operative or non-operative treatment. Patients who desire surgical treatment will need to accept a higher risk of adhesion, infection and disurbed sensation.

Dr. Boffeli is a Fellow and is currently on the Board of Directors for the American College of Foot and Ankle Surgeons. He is also the Residency Director at Regions Hospital, a Level 1 Trauma Center in St. Paul, Minn.

Dr. Richie is an Adjunct Associate Professor in the Department of Applied Biomechanics at the California School of Podiatric Medicine at Samuel Merritt College. He is a Past President of the American Academy of Podiatric Sports Medicine.

 




References:

1. Khan RK, Fick D, Brammar TJ, Crawford J, Parker MJ. Surgical interventions for treating acute Achilles tendon ruptures. Cochrane Database Syst Rev 3, 2004.
2. Costa ML, MacMillan K, Halliday D, et al. Randomised controlled trials of immediate weight-bearing mobilisation for rupture of the tendo Achilles. J Bone Joint Surg Br. 88-B: 69-77, 2006.

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