Does accelerated functional rehabilitation after surgery improve outcomes in patients with acute achilles tendon ruptures?
ABSTRACT To compare the outcomes of patients with acute Achilles tendon ruptures treated operatively with subsequent accelerated functional rehabilitation or nonoperatively with the same rehabilitation regimen.
Randomized controlled trial, with a minimum 2-year follow-up. Sample size was calculated with 80% power to show a minimum difference of 11% in rerupture rate at P ≤ 0.05. Patients who were lost to follow-up (12%) were excluded from the analysis.
Two university hospitals in Canada.
Patients presenting within 14 days of an acute Achilles tendon rupture (a positive Thompson squeeze test and a palpable gap), who were 18-70 years, and who were able to comply with the rehabilitation protocol were eligible. Exclusion criteria were open or additional ipsilateral injury, fluoroquinolone-associated rupture, avulsion from the calcaneus, diabetes, diseases requiring medications that impair tendon healing, and surgical contraindications. The 144 patients randomized had a mean age of 40 years, 82% were men, and 85% of the injuries were sport related.
Surgical treatment included a vertical posteromedial incision to the level of the paratenon. The tendon tear was closed with nonabsorbable sutures in a Krackow-type stitch pattern, using the contralateral extremity as a guide to tendon length. The paratenon and skin were closed. Postoperatively, or as soon as possible after the injury in the nonoperative group, a posterior back slab splint was applied with the foot in 20 degrees of plantar flexion. The patients were advised to use crutches and not to bear weight. After 2 weeks, the back slab was removed. An Aircast (Summit, New Jersey) walking boot was worn for about 6 weeks. The accelerated functional rehabilitation program included progressive resistance, fitness, and range-of-motion exercises. Weight bearing was permitted as tolerated. After 12 weeks, sport-specific retraining could be commenced.
The primary outcome was the 2-year rate of rerupture, diagnosed as previously, plus loss of plantar flexion strength. Secondary outcomes included isokinetic strength (assessed with a dynamometer), peak planter flexion and dorsiflexion torques at several velocities, range of motion, calf circumference, and the Leppilahti score, which includes patient ratings and objective measurements.
Reruptures occurred during the first 3 months after the initial injury, 2 in the operative group (3.2%) and 3 in the nonoperative group (4.6%). After 2 years, both groups were able to achieve a mean of 80% of the plantar flexion strength and 100% of the dorsiflexion strength of the unaffected limb. A difference in favor of the operative group, in the ratio of affected to unaffected limb in planter flexion strength at 240 degrees per second that was shown after 1 year, was slightly greater after 2 years (mean difference between groups, 14.15%; 95% confidence interval [CI], 1.12%-27.9%). The unaffected limb maintained a greater range of motion than the affected limb at each follow-up. The side-to-side difference in plantar flexion range of motion was greater in the operative than the nonoperative group (difference, 2.21%; 95% CI, 3.9%-0.5%), but the groups did not differ in dorsiflexion. After 1 and 2 years, the groups did not differ in calf circumference or Leppilahti score. Including the 5 reruptures, there were 13 complications in the operative group and 6 in the nonoperative group (difference, 9%; 95% CI, 1.2%-20.7%). There was 1 deep vein thrombosis in each group, and 1 case of serious pain and 1 failure to heal in the nonoperative group. The remaining 10 (mostly soft tissue) complications in the operative group included 1 deep infection and 1 pulmonary embolus.
Patients with acute Achilles tendon ruptures treated with accelerated functional rehabilitation recovered as well whether the initial treatment was surgical or not. Rates of rerupture were also similar and the rate of complications was lower for nonoperative treatment.