Surgeons routinely make treatment decisions based on their training and experience. For example, we typically employ non-operative treatment of Achilles ruptures for the elderly. Surgical repair, on the other hand, is usually recommended for younger, active patients. The traditional teachings on the long-term outcome after Achilles rupture tend to lump conservative treatment of acute rupture with non-operative treatment of delayed presentation and neglected rupture. Surgeons learn that non-operative treatment results in slow healing, weakness, calf atrophy, re-rupture and loss of function.
The problem with this approach is that we cannot ignore the strong evidence supporting conservative treatment via a brace and early weightbearing. Rather than being limited by our biases, the decision to perform surgery or cast a ruptured Achilles tendon is a clinical problem best answered through critical analysis of the best available evidence.
A Closer Look At The Current Literature
The decision to perform surgery or cast an Achilles rupture is a therapy question. The best evidence for a therapy question is a systematic review or meta-analysis of randomized controlled trials (RCTs) that represent Level 1 evidence.
In a meta-analysis of 14 RCTs, Khan, et al., evaluated treatment options for acute Achilles ruptures. This meta-analysis included four RCTs that compared surgical to conservative treatment in 356 patients. The authors concluded that surgical repair significantly decreased the risk of re-rupture (3.5 percent with surgery vs. 12.6 percent with non-operative treatment). However, the authors also found that surgery significantly increased the risk of other complications related to adhesion, infection and disturbed sensation (34 percent with surgery versus 2.7 percent with non-operative treatment).1
In the meta-analysis, the authors noted no statistically significant difference in the power of plantarflexion or heel raise endurance when comparing surgical to non-operative treatments. In three of four RCTs, patients returned to sports after treatment for Achilles ruptures. One study identified a better return to the original level of sports with surgery versus cast treatment alone while two studies showed no statistically significant difference.
The non-operative control groups in these RCTs (Khan, et al.) wore a plantarflexed cast without weightbearing or early range of motion. On the other hand, researchers described functional bracing as a removable brace that prevented dorsiflexion yet allowed immediate weightbearing, plantarflexion and physical therapy.
Khan, et al., evaluated the results of two RCTs that compared non-operative treatment in a traditional cast versus non-operative treatment in a functional brace. The functional brace group represented a small number of patients but demonstrated a re-rupture rate of 2.4 percent. Pooled data from other studies showed a re-rupture rate of 3.5 percent with operative treatment.1
In two independent RCTs, Costa, et al., studied the effectiveness of the functional brace. The first trial evaluated postoperative care via the traditional non-weightbearing cast versus immediate weightbearing in a functional brace. The second trial compared conservative treatment with a traditional non-weightbearing cast versus immediate walking in a functional brace.
The results showed that immediate walking in a brace improved functional outcome after surgery. Non-operative treatment with immediate weightbearing in a functional brace demonstrated no evidence of functional benefit or harm. Costa, et al., recommended “immediate weightbearing mobilization for rehabilitation of all patients with acute rupture of the tendo Achilles.”2
Translating The Evidence Into Practice
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.
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.
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.