Journal Club

Volume 3 - Issue 9

Journal Club

Myhrvold SB, et al. Nonoperative or surgical treatment of Acute Achilles' Tendon Rupture. N Engl J Med. 2022;386:1409-1420.

Background

Whether surgical repair of an acute Achilles' tendon rupture by an open-repair or minimally invasive approach is associated with better outcomes than nonsurgical treatment is not clear.

Methods

We performed a multicenter, randomized, controlled trial that compared nonoperative treatment, open repair, and minimally invasive surgery in adults with acute Achilles' tendon rupture who presented to four trial centers. The primary outcome was the change from baseline in the Achilles' tendon Total Rupture Score (scores range from 0 to 100, with higher scores indicating better health status) at 12 months. Secondary outcomes included the incidence of tendon rerupture.

Results

A total of 554 patients underwent randomization, and 526 patients were included in the final analysis. The mean changes in the Achilles' tendon Total Rupture Score were -17.0 points in the nonoperative group, -16.0 points in the open-repair group, and -14.7 points in the minimally invasive surgery group (P=0.57). Pairwise comparisons provided no evidence of differences between the groups. The changes from baseline in physical performance and patient-reported physical function were similar in the three groups. The number of tendon reruptures was higher in the nonoperative group (6.2%) than in the open-repair or minimally invasive surgery group (0.6% in each). There were 9 nerve injuries in the minimally invasive surgery group (in 5.2% of the patients) as compared with 5 in the open-repair group (in 2.8%) and 1 in the nonoperative group (in 0.6%).

Conclusions

In patients with Achilles’ tendon rupture, surgery (open repair or minimally invasive surgery) was not associated with better outcomes than nonoperative treatment at 12 months.

Comments of Dr. S. Chockalingam

Tendo Achilles rupture treatment has been extensively studied in the past. There has been enough literature to suggest that the results may not be different whether one treats conservatively or by surgery (both Minimally invasive percutaneous technique and open technique).

However, one has to note the following points.

1. There is a higher re-rupture rate at one year in those treated conservatively. The authors of this paper also agree with this. However, this should have been mentioned in the conclusion. especially when it is 6.2% vs 0.6%.
2. This also questions the concluding statement "surgery is not associated with better outcomes".
3. Return to work and function in the short term is superior in those who are operated by surgery, though at one year, the functional results may be the same. This is important for a breadwinner of the family or homemaker who multi-tasks for the family.
4. In India, these ruptures are commonly seen as open injuries associated with Indian toilets/accidents where conservative treatment is clearly out of the question.
5. Late presentations are also very common. This would cause retraction of the tendon ends, surgery is ideal.

To conclude, the paper reiterates the fact that a surgeon should balance the risks and benefits of surgery when advising treatment of this condition of tendo Achilles ruptures. In low-demand patients, conservative treatment is recommended as opposed to high-demand patients, with sports injuries, open injuries, delayed presentation, and those who expect to return to normal function early.

It is also important to note the post-op protocol has evolved to short immobilization of two weeks and controlled mobilization of a splint to optimize the results.

Dr. S. Chockalingam

Senior Consultant, Orthopaedic Surgeon